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CALIFORNIA  COLLEGE  OF  MEDICINE 

LOS  ANGELES,  CALIFORNIA 


MODERN  METHODS  OF  TREA  TMENT 


SERUMS,  VACCINES,  AND  TOXINS 


SERUMS,  VACCINES 
AND   TOXINS 

IN    TREATMENT   AND    DIAGNOSIS 

BY 

WM.  CECIL  BOSANQUET 

M.A.,  M.D.  OXON.,  F.R.C.P.  LOND. 

Physician    to   the   Charing   Cross   Hospital   and   to 

the    Hospital   foy    Consumption    and    Diseases    of 

the   Chest,    Brompton ;    sometime   Fellow   of  New 

College,  Oxford 


JOHN  W.  H.  EYRE 

M.D.,    M.S.  DUNELM.,   F.R.S.  EDIN. 

Director  of  tkt  Bacteriological  Department  of  Guy's 

Hospital  and  Lecturer  in  Bacteriology  in  the  Medical 

School ;  sometime  Hunterian  Professor,  Royal  College 

of  Surgeons,  Eng. 


ILLUSTRATED 


THIRD     EDITION 


NEW    YORK 
FUNK    AND    WAGNALLS    COMPANY' 


First  Edition  1904 

Second  Edition  1909.    Reprint*?  1910 
Third  Edition  1916 


ALL    RIGHTS    RESERVED 


CONTENTS 


CHAPTER  PACK 

1.  IMMUNITY  AND  RESISTANCE  TO  DISEASE         ...      1 

2.  PREPARATION  AND  ADMINISTRATION  OF  SERUMS    .        .     41 

3.  BACTERIAL    VACCINES  :    THEIR    PREPARATION    AND 

ADMINISTRATION 59 

4.  SERUMS  AND  TOXINS  IN  DIAGNOSIS 76 

5.  DIPHTHERIA 94 

6.  TETANUS 138 

7.  SNAKE-BITE 157 

8.  HYDROPHOBIA  (RABIES) 168 

9.  SMALL-POX  AND  VACCINIA        .        .        ...        .  182 

10.  ANTHRAX  AND  GLANDERS 201 

11.  PLAGUE 206 

12.  CHOLERA .        .  220 

13.  ENTERIC  FEVER 229 

14.  DYSENTERY  AND  OTHER  BACILLARY  INFECTIONS     .        .  257 

15.  TUBERCULOSIS 270 

16.  TUBERCULOSIS  (concluded)         .        .        .        .        .        .  311 

17.  LEPROSY;  STREPTOTRICHOSIS  ;  RINGWORM       .        .        .  345 

18.  AFFECTIONS  DUE  TO  STREPTOCOCCI 349 

19.  OTHER  INFECTIONS  DUE  TO  Cocci    .        .        .        .        .  373 

20.  CATARRHAL  AFFECTIONS 398 

21.  DISEASES  DUE  TO  PROTO/OA 405 

22.  MALIGNANT  TUMOURS 422 

APPENDIX  :    VARIOUS    CONDITIONS    TREATED    WITH 
SERUMS,  ETC 434 

INDEX  .        .  447 


LIST   OF    ILLUSTRATIONS 

FIO.  PAGE 

1.  Action  of  haemolytic  serum 7 

2.  Effect  of  heat  on  haemolytic  serum 8 

3.  Addition   of  complement   from   normal  serum   to  heated 

immune  serum '.» 

4.  Diagrammatic  representation  of  agglutination  .        .         .14 
;">.  Diagram  illustrating  "  side-chain  "  hypothesis  .         .         .23 

6.  Diagrammatic  representation  of  haemolysis        .         .        .24 

7.  Diagram  of   cell  with  numerous  side-chains  produced  by 

stimulation  with  toxin 26 

8.  Diagram    illustrating   fixation    or   deviation    of    comple- 

ment   39 

9.  All-glass  serum-syringe 4'.» 

10.  The  opsonic  cycle 70 

11.  Opsonic  index,  showing  rapid  fall 70 

12.  Opsonic  index,  showing  less  marked  negative  phase         .  71 

13.  Opsonic  index,  showing  oscillation  about  normal  level     .  71 

14.  Opsonic  index,  showing  immediate  appearance  of  positive 

phase 71 

15.  Measuring-pipette  for  opsonin-estimation  ....     ,s."> 
Hi.  Edge  of  blood-film  preparation 86 

17.  Diagram  illustrating  process  of  saturation  of  diphtherial 

toxin  with  antitoxin        .         .  .  103 


LIST    OF    CHARTS 

CHART 

1.  Illustrating  effects  of  Chantemesse's  serum        .         .        .  237 

2.  Illustrating  effects  of  Chantemesse's  serum        .         .         .  238 

3.  Illustrating  efficacy  of  a  second  brand  of  antistreptococcic 

serum  after  failure  of  the  first       .....  :i."i7 


PREFACE    TO    THE    THIRD    EDITION 

THE  period — little  more  than  six  years — that  has  elapsed 
since  the  publication  of  the  second  edition  of  this  book  has 
been  so  fruitful  in  research,  and  has  witnessed  such  notable 
advances  in  methods  of  diagnosis  and  treatment,  that  an 
exhaustive  revision  of  its  contents  was  found  necessary, 
entailing  the  addition  of  nearly  one  hundred  pages  of  new 
matter.  Some  rearrangement  of  the  subjects  dealt  with 
has  also  seemed  advisable. 

The  most  striking  advance  in  the  field  of  therapeutics 
is  undoubtedly  the  scientific  employment  of  Chemotherapy, 
which  has  resulted  from  the  noteworthy  investigations  of 
the  late  Professor  Ehrlich  and  his  pupils ;  and  although 
the  inclusion  of  drug-treatment  in  a  volume  professedly 
devoted  to  the  use  of  serums  and  vaccines  may  appear 
illogical,  such  is  not  actually  the  case,  since  the  lethal 
action  of  arsenical  compounds  and  dye-stuffs  upon  certain 
protozoal  parasites  depends  upon  principles  fundamentally 
identical  with  those  governing  the  action  of  specific  serums 
upon  bacteria.  We  have  therefore  deemed  it  advisable  to 
devote  some  space  to  a  consideration  of  this  subject. 

Experience  gained  during  the  present  European  Wai- 
has  vindicated  in  a  most  convincing  manner  the  value  of 
prophylactic  vaccination  against  typhoid  fever — a  procedure 
which  appears  to  afford  a  protective  immunity  against  this 
disease,  second  only  in  efficiency  to  that  given  by  Jennerian 
vaccination  against  small-pox.  Other  lessons  taught  by 
the  campaign  are  less  definite ;  thus,  in  connection  with  the 
use  of  antitetanic  and  of  antimeningococcic  serum,  opinions 
are  still  divided  on  such  questions  as  the  size  and  frequency 
of  the  doses  used,  the  method  of  administration,  and  so 
forth.  On  these  points,  as  elsewhere  throughout  the  book, 


viii  PREFACE 

we  have  collated  the  published  experience  of  others,  as 
well  as  indicated  the  conclusions  drawn  from  our  own 
observation. 

Other  points  to  which  we  may  direct  attention  are  the 
extended  use  of  the  complement-fixation  reaction,  not  only 
in  the  form  of  the  well-established  Wassermann  test  for 
syphilis,  but  also  in  the  diagnosis  of  other  infections ;  the 
attempt  to  correlate  certain  physical  phenomena  with  this 
reaction ;  and  the  present  trend  of  opinion  on  the  use  of 
tuberculin  in  cases  of  pulmonary  tuberculosis,  on  which 
subject  the  confident  dicta  and  heroic  dosage  of  the 
enthusiasts  may  have  temporarily  dazzled  the  unwary 
practitioner  of  medicine. 

It  will  no  doubt  occur  to  the  critical  reader  that 
somewhat  brief  mention  is  made  of  the  dosage  of  ordinary 
bacterial  vaccines,  whether  autogenous,  stock  or  sensitized. 
The  omission  is  intentional,  for  the  reason  that  the  study 
of  the  standardization  of  vaccines  is  still  in  its  infancy, 
and  consequently  it  is  almost  impossible  to  compare  the 
effective  doses  of  vaccines  bearing  the  name  of  the  same 
micro-organism  but  emanating  from  different  laboratories. 
This  fact  is  especially  noticeable  in  connection  with  vaccines 
prepared  by  the  different  commercial  houses. 

A  word  of  warning  may  perhaps  not  be  out  of  place  in 
regard  to  the  intrusion  of  this  commercial  element  into  the 
field  of  bacterial  therapeutics,  and,  on  the  other  hand,  as  to 
the  need  for  careful  clinical  observation  of  cases  undergoing 
treatment  by  such  remedies. 

W.  C.  B. 

J.  E. 
March,  1916. 


SERUMS,  VACCINES,  AND  TOXINS 

IN   TREATMENT  AND   DIAGNOSIS 

CHAPTER  I 
IMMUNITY  AND  RESISTANCE  TO  DISEASE 

Acquired  resistance. — The  problem  of  the  nature  of 
disease  and  of  the  manner  in  which  living  bodies  resist 
and  recover  from  its  attacks  has  exercised  the  minds  of 
mankind  since  very  early  times,  and  the  fundamental  truth 
that  in  the  case  of  certain  diseases  one  attack  protects  against 
subsequent  infection  was  long  ago  discovered.  The  first 
attempt  to  utilize  this  principle  for  prophylactic  purposes 
was  made  in  the  East  in  the  form  of  inoculation  against 
small-pox,  a  mild  infection  being  produced  by  inoculation 
with  matter  derived  from  a  pustule,  in  order  to  ward  off 
danger  of  subsequent  infection.  Shortly  after  the  introduc- 
tion of  this  procedure  into  the  West  of  Europe,  Jenner's 
great  discovery  that  vaccination  with  cow-pox  was  equally 
efficacious  as  a  protection  and  practically  free  from  risk, 
laid  the  foundation  of  our  knowledge  of  therapeutic  inocu- 
lation. It  was  only,  however,  after  the  discovery  of  the 
minute  living  agents  which  cause  infective  diseases  had 
been  rendered  possible  by  improvements  in  optical  science 
that  further  advance  in  this  field  was  made.  When  bacteria 
were  recognized  as  the  cause  of  most  infective  diseases,  and 
their  mode  of  action  by  the  secretion  of  poisons  or  toxins 
was  ascertained,  research  into  the  problem  of  our  means 
of  resistance  to  these  invaders  was  stimulated  ;  and  from 
the  time  of  Koch's  invention  of  accurate  methods  for  the 
separation  and  identification  of  bacteria,  followed  as  it 

B 


2    SERUMS,  VACCINES,  AND  TOXINS 

was  at  no  distant  date  by  Behring  and  Kitasato's  work  on 
antitoxins  and  by  Pfeiffer's  experiments  in  bacteriolysis, 
knowledge  of  the  various  factors  involved  in  immunity 
has  steadily  advanced. 

Phagocytosis. — The  first  important  theoi-y  of  resistance 
to  disease  was  that  of  Metchnikoff  (1865-84),  who  studied 
the  behaviour  of  the  white  blood-corpuscles  (leucocytes)  in 
many  of  the  lower  animals,  and  attributed  the  destruction 
of  bacteria  in  the  body  to  the  activity  of  these  cells.  This 
was  the  well-known  theory  of  phagocytosis  (faye'tv,  to 
eat ;  K-WJ-OC,  a  cell).  According  to  Metchnikoff,  the  leuco- 
cytes attack  and  devour  any  invading  organisms  which 
they  may  meet,  and  thus  rid  the  body,  of  these  parasites^ 
just  as  they  may  be  seen  to  take  into  their  substance 
particles  of  any  foreign  matter  which  comes  in  their  way ; 
when  they  have  swallowed  and  thus  destroyed  all  the 
bacteria  which  have  gained  a  footing  in  the  body,  the 
disease  necessarily  comes  to  an  end. 

The  careful  and  minute  study  earned  out  by  the  French 
observer  cannot  be  too  much  admired,  and  there  can  be  no 
doubt  that  it  contains  a  large  proportion  of  truth.  Thus, 
the  assemblage  of  leucocytes  which  takes  place  at  any  focus 
of  irritation  is  almost  certainly  protective  in  character; 
and  it  has  been  shown  by  Kanthack  and  others  that  the 
granules  contained  in  the  protoplasm  of  the  leucocytes 
consist  of  substances  which  tend  to  combat  the  bacteria 
and  to  stop  their  growth.  But  in  man,  at  all  events,  this 
phagocytic  action  is  not  the  sole  factor  in  the  struggle  with 
the  invading  germs — possibly  not  even  the  most  important. 

Protective  power  Of  Serum. — Further  experiments 
showed  that  the  serum  of  the  blood,  even  when  all  formed 
elements,  such  as  the  corpuscles,  had  been  removed,  still 
exerted  in  many  instances  an  inhibitory  action  on  the 
growth  of  micro-organisms  (Nuttall,  Biichner).  There 
must,  therefore,  be  present  in  the  plasma  some  substance 
of  a  protective  nature,  and  to  such  hypothetical  substances 
Biichner  gave  the  name  "alexines."  It  is  by  means  of 


KESISTANCE   TO   DISEASE  3 

such  alexines  that  destruction  of  bacteria  is  in  many  cases 
brought  about ;  and  it  is  by  other  chemical  substances 
circulating  in  the  blood  that  the  poisonous  products  of  the 
organisms  are  neutralized. 

As  a  result  of  these  discoveries,  attention  was  directed 
for  a  time  mainly  to  the  chemical  contents  of  the  serum  and 
other  fluids,  and  the  importance  of  the  process  of  phago- 
cytosis was  seriously  called  in  question.  A  whole  series  of 
peculiar  properties  possessed  by  the  serum  of  immunized 
animals  was  brought  to  light,  and  was  used  to  support 
the  "  humoral  theory  "  of  immunity.  Here,  however,  as  in 
many  other  instances  in  which  opposing  theories  have  been 
hotly  upheld  and  attacked,  time  has  shown  that  each  side 
in  the  controversy  had  grasped  a  portion  of  the  truth,  but 
declined  in  the  heat  of  conflict  to  recognize  the  other  portion 
which  was  defended  by  their  antagonists.  The  upholders 
of  the  phagocytic  hypothesis  satisfactorily  proved  that  in 
many  important  affections  the  serum  alone  was  ineffective 
in  destroying  bacteria  and  that  the  action  of  leucocytes  was 
essential  for  the  process  of  defence,  and  maintained  further 
that  the  very  chemical  bodies  which  were  held  by  their 
opponents  to  constitute  the  basis  of  immunity  were  them- 
selves secreted  by  the  leucocytes  of  the  blood.  The  dis- 
covery of  a  special  group  of  substances  ("  opsonins,"  p.  18) 
existing  in  the  serum,  by  which  the  process  of  phagocytosis 
is  induced  or  at  least  facilitated,  has  to  some  extent  recon- 
ciled the  positions  of  the  opposing  schools.  Thus,  so  far  as 
is  at  present  known,  it  would  appear  that  both  phagocytosis 
and  bacteriolysis  (p.  7)  take  part  in  the  destruction  of 
bacteria  within  the  body,  now  one,  now  the  other  pre- 
dominating, according  to  the  nature  of  the  infective  agent. 

Resistance  Of  tissue-cells. — In  addition  to  the  fact 
that  protective  bodies  found  in  the  serum  are  almost  cer- 
tainly formed  by  the  cells  of  the  blood-forming  or  other 
tissues,  and  to  the  further  fact  that  certain  fixed  cells, 
notably  those  of  endothelial  surfaces,  possess  phagocytic 
power  it  can  hardly  be  doubted  that  the  tissues  of  different 


4    SERUMS,  VACCINES,  AND  TOXINS 

individuals  or  species  have  different  degrees  of  power  of 
resistance  to  the  attacks  of  bacterial  parasites.  For 
example,  in  pulmonary  tuberculosis  we  find  that  in  one 
case  the  lung-tissue  rapidly  breaks  down  and  is  destroyed  ; 
in  another,  little  damage  of  this  nature  results,  but  a  dense 
growth  of  fibrous  tissue  takes  place  and  effectually  localizes 
the  disease,  and  ultimately  repairs  the  mischief  done  by  the 
tubercle  bacilli.  So  little,  however,  is  known  of  this  tissue 
resistance  that  we  need  not  do  more  than  indicate  its 
existence  as  an  important  though  incalculable  factor  in  the 
problem  of  immunity. 

Antitoxins. — In  the  year  1890  Behring  and  Kitasato 
published  the  results  of  their  important  researches  on  the 
poison  of  tetanus  and  on  the  possibility  of  rendering  animals 
immune  to  it.  These  observers  proved  that  it  was  possible," 
by  injecting  animals  first  with  infinitesimal  quantities,  later 
with  increasing  doses,  of  the  toxins  of  tetanus,  to  render 
them  immune  to  the  disease.  The  animals  thus  treated 
were  able  to  support  with  impunity  doses  of  the  tetanus 
poison  many  times  as  great  as  would  suffice  to  kill  an 
ordinary  non-immunized  animal  of  the  same  species.  If 
the  serum  of  an  immunized  animal  were  mixed  with  an 
equivalent  amount  of  the  poison  and  injected  into  a  non- 
immune  animal,  no  ill  effects  were  produced ;  while  the 
injection  of  the  immune  serum  itself  into  a  non-immunized 
animal  rendered  the  latter  also  resistant  to  a  subsequent 
dose  of  the  toxin.  Finally,  if  a  sufficient  quantity  of  im- 
mune serum  were  administered  within  a  short  period  of 
time  to  an  animal  previously  inoculated  with  the  tetanus 
bacillus,  the  disease  did  not  develop. 

The  same  observers,  and  also  Wernicke,  shortly  after- 
wards showed  that  similar  possibilities  existed  with  regard 
to  the  bacillus  of  diphtheria — that  by  treating  animals  with 
the  toxins  of  this  organism  a  serum  could  be  obtained 
which  was  capable  of  neutralizing  the  poison,  and  which 
also  possessed  a  curative  effect  on  the  disease.  To  the 
unknown  substance  in  the  serum  which  had  the  property  of 


ANTITOXINS  5 

neutralizing  the  toxin  they  gave  the  name  of  antitoxin. 
The  antitoxic  bodies  formed  in  the  two  cases  were  not  the 
same ;  the  tetanus  antitoxin  did  not  act  as  an  antidote  to 
the  poison  of  diphtheria  nor,  conversely,  did  diphtherial  anti- 
toxin prove  efficacious  against  tetanus.  Each  serum  was 
"specific,"  neutralizing  only  the  poison  of  the  corresponding 
disease ;  and  this  peculiarity  has  been  found  to  exist  in 
all  subsequently  prepared  "immune  serums." 

In  the  light  of  these  discoveries  as  to  the  reaction  of 
living  animals  to  bacterial  toxins,  attention  was  turned  to 
the  effects  produced  by  other  organic  poisons,  and  it  was 
shown  by  Ehrlich  that  it  was  possible  to  immunize  animals 
to  the  vegetable  poisons  abrin  (from  jequirity),  ricin  (from 
castor  oil),  and  crotin  (from  croton  oil),  which  are  probably 
of  complex  proteid  nature,  and  resemble  ferments  in  their 
action.  In  the  case  of  each  of  these  substances  it  was  pos- 
sible to  obtain  a  specific  antitoxic  serum,  protecting  only 
against  its  appropriate  toxin.  Similarly,  in  the  case  of 
snake-venom  an  antitoxic  serum  was  prepared,  of  which 
use  has  been  made  therapeutically  with  some  degree  of 
success. 

Chemical  nature  of  antitoxins. — Examination  of  the 
blood  of  horses  used  for  the  preparation  of  diphtherial 
antitoxin  shows  that  the  globulin  content  of  the  serum 
is  increased.1  Further,  if  the  antitoxic  serum  obtained 
from  them  is  fractionally  precipitated  with  ammonium 
sulphate,  it  is  found  that  the  antitoxin  is  precipitated 
with  the  pseudo-globulin3 — that  portion  which  is  thrown 
down  by  semi-saturation  with  the  salt.  In  animals  other 
than  horses  (e.g.  goats)  the  antitoxin  may  be  thrown  down 
with  the  euglobulin  precipitate.  Hence  it  has  been  in- 
ferred that  the  antitoxin  is  a  globulin.  This  cannot  be 
regarded  as  definitely  proved,  since  substances  are  often 
carried  down  with  precipitates  from  which  they  are 

1  This  is  denied  by   Ledingham.   Joiirn.   of  Hygiene,  1907,  vii. 
65,  92. 

2  Pick,  Hofmeister's  Beitr.,  1901,  p.  1384. 


(5          SERUMS,    VACCINES,    AND   TOXINS 

chemically  distinct  (e.g.  ferments).  Proescher l  believes 
that  antitoxins  are  non-albuminous,  but  their  non-dialys- 
able  character  points  to  the  probability  of  their  molecules 
being  large  in  size,  and  therefore  complex  in  structure,  as 
are  all  the  albuminoids. 

Antibacterial  Serum. — It  may  here  be  pointed  out 
that  in  order  to  prepare  an  antitoxic  serum  it  is  necessary 
to  obtain  the  toxin  of  the  bacterium  in  question  for 
the  purpose  of  injection  into  animals.  In  the  case  of 
diphtheria  and  tetanus  this  is  easily  done.  In  the  case 
of  many  organisms,  however,  difficulties  arise,  since  their 
poison  is  not  secreted  into  culture-media,  but  remains  in 
the  bodies  of  the  bacteria  themselves.  Such  poisons  are 
spoken  of  as  "  endotoxins "  :  it  is  not  certain  whether 
they  consist  of  the  actual  protoplasmic  substance  of 
the  bacteria  or  are  separate  products,  analogous  to  the 
poisonous  alkaloids  formed  by  some  plants  (strychnine, 
morphine).  In  such  instances,  if  the  actual  germs  are 
injected  into  animals,  beginning  with  minute  doses  of 
attenuated  cultures  and  gradually  increasing  until  large 
quantities  of  virulent  bacteria  can  be  tolerated,  in  most 
cases  a  serum  is  produced  which  is  not  antitoxic  in  the 
sense  of  neutralizing  the  poisons  of  the  micro-organism,  but 
•which  destroys  the  bacteria  themselves  when  they  are 
submitted  to  its  action.  Such  a  serum  is  said  to  be 
"antibacterial"  or  "bactericidal,"  instead  of  antitoxic.  Thus, 
if  an  animal  is  injected  with  cholera  vibrios  until  it  is  very 
resistant  to  these  germs,  and  then  a  little  of  its  blood-serum 
is  added  to  a  culture  of  these  organisms,  the  latter  are  found 
to  undergo  degeneration,  and  finally  to  be  completely  dis- 
integrated ;  but  no  quantity  of  this  serum  will  neutralize  a 
lethal  dose  of  the  poison  of  the  cholera  germ.  On  the  other 
hand,  an  antitoxic  serum  has  no  effect  in  preventing  the 
growth  of  the  appropriate  organism  ;  for  instance,  diph- 
therial  antitoxin  is  a  very  favourable  culture-medium  for 
the  Klebs-Loffler  bacillus.  The  process  of  destruction  of 
1  MiiHcJi.  med.  Wwh.,  1902,  p.  1176. 


HAEMOLYSIS 


bacteria  by  an  antibacterial  serum  is  called  "  bacteriolysis," 
and  the  property  resides  not  only  in  the  blood-serum,  but 
also  in  other  vital  fluids,  such  as  the  peritoneal  exudate. 
It  is  evident  that  some  special  substance  is  produced  in  the 


Fowl's 
corpuscles 


Normal 
rabbit's  serum 


Fowl's 
corpuscles 


Immune' 
serum 


No  solution 
of  corpuscles 


Solution 
of  corpuscles 


Fig.  1 — Action  of  haeraolytic  serum. 

bodies  of  the  immunized  animals,  which  acts  as  a  solvent  of 
the  bacterial  protoplasm. 

Haemolysis! — Further  research  showed  that  it  is  not 
only  bacteria  which,  by  injection  into  living  animals,  give 
rise  to  the  production  of  substances  destructive  to  them- 
selves. In  1891  Bordet,  to  whom  much  of  our  knowledge 
of  the  phenomena  of  bacteriolysis  is  due,  discovered  that, 
if  the  blood  of  one  species  of  animal  were  injected  into 


8    SERUMS,  VACCINES,  AND  TOXINS 

an  individual  of  another  kind,  the  serum  of  the  latter- 
developed  the  property  of  dissolving  the  corpuscles  of 
animals  of  the  former  species.  Thus,  if  the  blood  of  a  fowl 
is  injected  into  a  rabbit,  the  serum  of  the  rabbit  gains  the 
power  of  dissolving  the  corpuscles  of  fowl's  blood  when 


Fowl's 
corpuscles 


Immune  serum 
heated  to  60°C. 


No  solution 
of  corpuscles 

Fig.  2. — Effect  of  heat  on  hajmolytic  serum  (destruction  of  complement). 

added  to  it  in  a  test-tube.  This  phenomenon  is  called 
"haemolysis,"  and  the  hsemolytic  power  is  exactly  analogous 
to  the  bacteriolytic  property  in  the  cases  previously  described. 

Copula  and  complement. — Now,  if  the  huemolytic 

serum  of  the  rabbit  in  this  experiment  is  heated  to  56°  C.  or 
60°  C.,  it  loses  its  solvent  power  ;  but  if  a  little  serum  from 
a  normal  rabbit  is  added  to  the  heated  serum,  the  property 
of  dissolving  the  fowl's  corpuscles  returns  to  it. 


COPULA   AND   COMPLEMENT  9 

The  same  occurs  in  the  case  of  bacteriolytic  serum. 
Thus  Pfeiffer  showed  that  in  the  peritoneal  cavity  of  an 
immunized  guineapig  cholera  vibrios  undergo  a  process  of 
destruction,  and  that  the  same  occurs  in  a  test-tube  con- 
taining serum  derived  from  such  an  animal.  If  this  serum 


Fowl's 
corpuscles. 


Immune  serum 
heated  to60°C. 


Normal  ^ 
rabbit's  serum. 


.Solution 
of  corpuscles 

Fig.  3. — Addition  of  complement  from  normal  serum  to 
heated  immune  serum. 

is  heated,  it  loses  its  potency.  If,  however,  a  little  of  this 
heated  serum  is  injected  along  with  cholera  germs  into 
the  peritoneal  cavity  of  a  non-immune  guineapig,  solution 
takes  place,  the  peritoneal  fluid  of  the  normal  guineapig 
supplying  the  substance  which  was  destroyed  by  the  heat. 

The  accompanying  diagrams  (Figs.   1,   2,   3)  will  make 
these  statements  more  clear. 


10         SERUMS,    VACCINES,    AND    TOXINS 

From  this  it  is  apparent  that  in  the  process  of  haemo- 
lysis the  interaction  of  two  bodies  is  necessary  to  bring 
about  the  result.  One  of  these — the  complement  or  alexine 
(a) — is  present  in  normal  serum,  whereas  the  second — the 
copula  or  immune  body  (b) — is  only  developed  in  immunized 
animals.  The  former  (a)  is  quickly  destroyed  by  heat, 
whereas  the  latter  (b)  is  more  stable  and  is  i-esistant  to  it. 
The  complement  is  probably  of  ferment-like  nature,  and  the 
process  of  destruction  has  been  supposed  to  be  one  of 
hydrolysis  (Turro).1 

The  multiplicity  of  names  applied  to  these  two  bodies  by 
different  writers  may  possibly  lead  to  some  confusion.  We 
may  tabulate  them  thus  : — 

(a)  Complement  (always  present),      {(b)  Copula  (developed  in  im- 
called  also —  munized  animals),  called 

Alexine.  also — 

Addiment.  Intermediary  ~_body. 

Cytase.  Immune  body. 

Amboceptor. 

Fixative. 

Mediator. 

Desmon. 

Preparateur. 

Substance  sensibilisatrice. 

Sensitizing  substance. 

Perhaps  the  words  complement  and  copula  are  as  con- 
venient as  any  to  denote  these  substances  respectively. 

The  foregoing  experiments  do  not  succeed  if  the  serum 
and  corpuscles  be  kept  at  a  low  temperature  (0°  C.).  If, 
however,  a  mixture  of  hsemolytic  serum  and  corpuscles  is 
made  and  kept  at  this  degree  of  temperature,  and  then  the 
corpuscles  are  separated  from  the  serum  and  washed  clean 
by  saline  solution,  it  is  found  that  they  are  now  destroyed 
by  the  addition  of  a  normal  (non-hsemolytic)  serum.  This 
shows  that  the  copula  or  intermediary  body  has  become 
fixed  to  the  corpuscles  in  some  way,  so  that  these  are  now 
"  sensitive  "  to  the  action  of  the  complement  contained  in 

1  Berlin.  Jdin.  Woch.,  Sept.  7,  1903. 


CYTOLYSIS  11 

normal  serum.  For  this  reason  the  copula  has  been  called 
by  French  writers  the  "  sensitizer  "  or  "  preparator  "  (sub- 
stance sensibilisatrice  ;  preparateur) .  Use  is  made  of  cor- 
puscles— or  of  bacteria,  for  the  same  occurs  in  their  case 
also — thus  sensitized,  for  the  purpose  of  experiments, 
to  which  further  allusion  will  be  made  on  a  subsequent 
page  (see  p.  36). 

The  serum  of  certain  animals  is  found  to  be  actively 
destructive  of  the  corpuscles  of  those  of  another  species, 
without  the  necessity  for  any  preliminary  treatment  by  in- 
jection of  the  blood-corpuscles  derived  from  the  latter.  Thus 
the  serum  of  the  eel  produces  rapid  haemolysis  if  injected 
into  mammalian  animals,  and  hence  is  highly  poisonous  in 
its  action.  It  is  probable  that  in  this  case  the  intermediary 
body  or  copula  necessary  for  the  action  upon  blood-corpuscles 
of  a  ferment  already  existing  in  the  mammalian  blood  is 
supplied  by  the  serum  of  the  eel.  In  other  cases  minor 
degrees  of  the  same  toxicity  may  be  observed,  the  serum 
of  many  animals  exerting,  without  preliminary  treatment, 
a  limited  degree  of  haemolytic  action  on  the  corpuscles  of 
other  species. 

In  some  diseases,  haemolytic  substances  may  develop  in 
human  blood,  capable  of  acting  on  the  blood  of  another 
human  individual  (isolysins).  The  possibility  of  the  exist- 
ence, in  diseases  characterized  by  extreme  bloodlessness, 
such  as  pernicious  and  splenic  anaemia,  of  substances  of  the 
nature  of  copulas,  which  unite  with  the  complement  present 
and  thus  lead  to  the  destruction  of  the  patient's  own  blood- 
corpuscles,  opens  up  an  interesting  field  of  speculation  ; 
but  there  is  as  yet  little  definite  evidence  of  the  existence 
of  such  substances  (autolysins). 

Cytolysis.— It  is  found  that  similar  "  antibodies  "  are 
produced  by  the  injection  into  a  living  animal  not  only  of 
bacteria  and  blood-corpuscles,  but  of  many  other  kinds  of 
cells,  as,  for  instance,  spermatozoa,  nerve-cells,  leucocytes, 
liver-cells,  gastric  epithelium,1  etc.,  provided  that  such  cells 
1  Bolton,  Trans.  Path.  Soc.,  1906,  Ivii.  297. 


12         SERUMS,    VACCINES,    AND    TOXINS 

are  derived  from  an  animal  of  a  different  species.  Serum 
from  an  animal  thus  injected  with  spermatozoa  derived 
from  another  species  is  found  to  contain  a  substance 
(cytolysin)  capable  of  destroying  the  spermatozoa  existing 
within  the  living  body  of  an  individual  of  the  latter  species. 
The  question  of  the  possibility  of  preparing  a  serum  which 
should  be  capable  of  destroying  the  cells  of  a  tumour,  e.g. 
a  cancer,  without  affecting  the  normal  epithelium,  is  of 
interest  in  relation  to  the  treatment  of  such  disease. 

Any  substance  the  injection  of  which  into  a  living 
animal  induces  the  formation  of  a  specific  antagonistic 
body  is  called  an  antigen;  and  conversely,  such  an  an- 
tagonistic substance  (see  p.  29)  capable  of  interacting  with 
its  antigen  is  termed  an  antibody. 

Precipitation. — Very  closely  allied  to  this  formation  of 
cytolysins,  or  substances  which  are  capable  of  dissolving 
cells,  is  the  appearance  of  materials  which  act  in  a  peculiar 
way  on  the  soluble  albuminous  substances  contained  in 
serum  itself.  These  are  called  precipitins,  and  are  formed 
when  the  serum  of  one  kind  of  animal  or  some  similar 
albuminous  fluid  is  injected  into  the  body  of  another 
species.  Thus,  if  the  serum  of,  say,  a  horse  is  injected 
into  a  goat,  the  serum  of  the  latter  acquires  the  property 
of  forming  a  precipitate  with  normal  horse's  serum.  The 
precipitate  is  apparently  formed  at  the  expense  of  the 
"  immune  serum  "  (i.e.  that  of  the  animal  which  has  re- 
ceived the  preliminary  injection  of  foreign  albumin),  not 
of  the  normal  serum.  It  was  suggested  by  Uhlenhuth 
that  use  might  be  made  of  this  fact  to  constitute  a  test  for 
different  kinds  of  blood.  The  possession  of  such  a  test  for 
human  blood  would  be  of  considerable  medico-legal  value ; 
but  unfortunately  this  particular  test  is  not  so  absolutely 
specific  as  might  be  wished,  since  the  serum  of  the  injected 
animal  is  found  to  give  a  precipitate  not  only  with  the 
serum  of  the  actual  species  of  animal  used  to  inoculate  it, 
but  also  with  the  blood  of  closely  allied  species  (e.g.  apes 
and  man).  Further,  it  must  be  borne  in  mind  that  the 


AGGLUTINATION  13 

test  is  one  for  distinguishing  between  albuminous  sub- 
stances derived  from  different  species,  and  not  for  blood 
alone. 

Some  authorities  l  deny  that  even  this  limited  degree  of 
specificity  exists,  finding  that  a  precipitating  substance, 
formed  by  injecting  human  blood  into  an  animal — which 
therefore  should  act  solely  on  human  or  anthropoid  blood — 
will  react  also  with  that  of  oxen,  horses,  sheep,  pigs,  etc. 
The  most  pronounced  action  is,  however,  on  human  blood, 
and,  according  to  these  authors,  error  may  be  avoided  by 
diluting  the  serum.  Thus  an  efficient  precipitating  serum 
diluted  to  1  in  1,000  will  react  only  with  the  blood  of  the 
animal  with  which  it  was  prepared.  It  is  possible,  there- 
fore, that  with  this  modification  the  test  may  still  prove  to 
possess  a  field  of  usefulness.  The  age  of  the  blood  used — 
stains  on  linen,  etc. — does  not  affect  the  reaction. 

Agglutination. — The  serum  of  animals  treated  by 
injection  of  the  blood  of  another  species  possesses,  in 
addition  to  its  destructive  action,  a  power  of  agglutinating 
the  blood-corpuscles  of  the  latter,  i.e.  causing  them  to 
adhere  together.  This  property  is  not  lost  on  heating 
the  serum  to  55°  C.  H.  Marx  and  Ehrnrooth2  found 
that  human  corpuscles  are  agglutinated  by  the  serum  of 
any  other  animal,  and  suggested  the  use  of  this  property 
as  a  medico-legal  test. 

When  the  serum  of  animals  which  have  suffered  from 
a  bacterial  disease,  or  which  have  been  inoculated  with 
a  micro-organism,  is  added  to  a  culture  of  the  bacteria 
in  question,  it  causes  them  to  stick  together  in  clumps  or 
masses,  instead  of  floating  separately  in  the  culture-fluid 
(Fig.  4).  The  best-known  instance  of  this  is  the  reaction 
produced  by  the  serum  of  a  patient  suffering,  or  who 
has  recovered,  from  enteric  fever,  when  it  is  added  to  a 
culture  of  the  Bacillus  typhosus.  It  is  found  that  if  we  take 
a  young  and  vigorous  culture  of  typhoid  bacilli  in  broth,  and 

1  Linessier  and  Lemoine,  Gaz.  des  Hop.,  March  27,  1902. 

2  Miinch.  med.  Woch.,  Feb.  16,  1904,  p.  293. 


14         SERUMS,   VACCINES,    AND    TOXINS 

add  to  it  a  small  quantity  of  the  serum  of  a  patient  with 
enteric  fever,  the  bacilli  almost  immediately  cease  their  nor- 
mal active  movement,  and  soon  become  collected  together 
into  clumps.  The  hypothetical  bodies  on  which  this  reac- 
tion depends  are  called  agyhitinins.  The  discovery  of  this 
phenomenon  is  due  to  Griiber  and  Durham,  and  experi- 
ments were  made  with  regard  to  its  clinical  possibilities  by 
Grunbaum ;  but  Widal  first  published  his  results,  showing 
the  possible  use  of  the  phenomenon  as  a  test  for  the  exist- 
ence of  enteric  fever,  and  the  reaction  is  generally  associated 


Fig.  4. — Diagrammatic  representation  of  agglutination. 
A,  Free  bacilli ;  B,  bacilli  agglutinated. 

with  his  name.  Not  only  are  typhoid  bacilli  agglutinated 
by  their  appropriate  serum,  but  the  same  phenomenon 
occurs  with  other  organisms,  such  as  the  Micrococcvs 
melitensis  of  Mediterranean  fever,  the  bacillus  of  dysentery 
(Shiga),  the  vibrio  of  cholera,  tubercle  bacilli,  etc. 

It  was  at  first  thought  that  the  property  of  agglutinat- 
ing bacteria  was  "  specific,"  i.e.  that  a  serum  would  only 
clump  the  particular  kind  of  organism  which  had  been 
injected  into  the  animal,  or  which  had  caused  disease  in  the 
patient.  This  appears  to  be  only  generally  true.  On  the 
one  hand,  it  is  found  that  a  certain  degree  of  agglutinative 
power  towards  many  different  kinds  of  bacteria  may  exist 
in  normal  blood,  so  that  inoculation  or  disease  only  increases 


AGGLUTINATION  15 

an  already  existing  property ;  on  the  other  hand,  it  appears 
that  in  some  cases,  at  all  events,  treatment  with  a  parti- 
cular organism  may  increase  the  agglutinative  power  as 
affecting  other  varieties  of  germs.  Thus,  in  a  case  quoted 
by  Posselt  and  Sagasser,1  it  was  found  that  the  serum  of  a 
rabbit  before  treatment  possessed  an  agglutinating  power 
against  typhoid  bacilli  in  a  dilution  of  1  :  10 ;  against  colon 
bacilli,  1:8;  against  cholera  vibrios,  1  :  10;  and  against 
Shiga's  bacilli  (dysentery),  1  :  5.  After  inoculation  with 
colon  bacilli,  the  figures  rose  to — B.  typhosus,  1  :  150  ;  B. 
coli,  1  :  650 ;  V.  cholerce,  1  :  50 ;  and  B.  dysenteries,  1  :  80. 
Thus  treatment  with  one  organism  may  apparently  inci;ease 
the  agglutinative  power  against  a  number  of  others,  and 
hence  the  property  cannot  be  looked  on  as  quite  specific. 
It  is  noticeable,  however,  that  the  clumping  power  towards 
the  bacilli  injected  rose  much  more  rapidly  and  to  a  vastly 
higher  point  than  that  towards  other  organisms. 

Nature  of  the  agglutinative  process.— That  the 

agglutinating  power  depends  on  a  definite  substance  present 
in  the  serum  is  shown  by  the  fact  that  it  is  possible  to 
exhaust  the  agglutinin  in  a  specimen  of  serum  by  adding 
a  sufficient  amount  of  the  bacteria  on  which  it  acts.  Thus, 
if  we  continually  add  fresh  quantities  of  typhoid  bacilli 
to  the  serum  derived  from  a  patient  suffering  from  enteric 
fever,  there  at  length  comes  a  time  when  no  further 
aggregation  of  the  organisms  takes  place.  But  such  a 
specimen  of  serum  may  still  agglutinate  other  organisms, 
as,  for  instance,  B.  dysenteries.  This  proves  that  different 
substances  serve  as  agglutinins  for  different  species  of 
organisms. 

The  agglutinins  are  in  all  probability  not  the  same  as 
the  other  antibacterial  bodies  by  which  immunity  is  brought 
about  (bacteriolysins,  opsonins,  etc.),  but  in  the  majority  of 
cases  they  seem  to  be  developed  in  the  serum  pari  passu 
with  the  latter.  It  has  therefore  been  suggested  that  the 
agglutinating  power  might  be  used  as  a  criterion  of  the 
1  Wien.  MM.  JJ'och  ,  1903,  No.  24,  p.  691. 


16         SERUMS,    VACCINES,    AND    TOXINS 

strength  of  an  immune  serum ;  and  Koch  considered  that 
in  tuberculosis  the  agglutinative  power  possessed  by  the 
serum  is  actually  an  index  of  the  patient's  power  of  re- 
sistance. It  is  probable,  however,  that  no  single  one  of 
the  different  bodies  produced  in  the  serum  of  immunized 
animals  can  be  taken  by  itself  as  a  measure  of  the  total 
degree  of  immunity. 

The  exact  method  by  which  the  agglutination  of  bacteria 
by  their  appropriate  serum  is  brought  about  is  not  under- 
stood. It  has  been  suggested  that  it  is  owing  to  some 
alteration  of  their  covering  membrane,  so  that  they  are 
rendered  liable  to  be  wetted  by  the  fluid  in  which  they 
are  floating  (Defalle).1  Bodies  which  are  wetted  by  a 
liquid  in  which  they  are  suspended  tend  to  adhere  to  one 
another,  while  those  which  are  not  so  wetted  tend  to  repel 
each  other. 

A  more  probable  explanation  is  that  some  proteid  sub- 
stance is  precipitated  by  the  action  of  the  serum  and  binds 
the  bacteria  together  in  its  meshes.  It  is  noteworthy  that 
in  old  cultures  of  typhoid  bacilli  an  agglutinative  substance 
passes  out  into  the  culture-fluid,  so  that  the  addition  of  a 
portion  of  such  fluid,  freed,  from  organisms,  confers  on  a 
normal  serum  the  power  of  agglutinating  the  bacilli.  The 
relation  between  precipitins  and  agglutinins  is  probably 
very  close. 

It  would  appear  that  two  separate  bodies  take  part  in 
the  process  of  agglutination  (analogous  to  the  two  required 
for  bacteriolysis,  haemolysis,  etc.),  one  being  destroyed  by 
heat,  while  the  other  is  relatively  thermostable.  Thus, 
Bail  *  finds  that  the  serum  of  a  patient  suffering  from 
enteric  fever  loses  its  agglutinative  power  if  heated  to 
70°  C.,  but  that,  if  normal  serum  is  subsequently  added  to 
a  suspension  of  the  bacilli  (B.  typhosus)  in  this  heated 
serum,  clumping  will  then  occur.  The  thermostable  body 
left  after  heating  has  been  termed  agglutinoid.  Bacteria 

1  Ann.  dt  VInst.  Patttur,  1902,  xvi.  595. 

2  Prayer  mod.  Woeh.,  1901,  Nos.  32  and  33. 


AGGLUTINATION  17 

which  have  been  in  contact  with  agglutinoid  fail  to  clump 
on  subsequent  addition  of  agglutinin. 

A  peculiar  phenomenon  ("zone  of  inhibition"  or  "pro- 
zone  ")  sometimes  observed,  viz.  that  some  serums  may 
produce  agglutination  when  diluted  but  not  when  con- 
centrated, has  been  explained  on  this  basis :  If  there  is 
present  a  large  amount  of  agglutinin  along  with  a  small 
amount  of  agglutinoid,  but  the  latter  has  greater  affinity 
for  the  bacteria,  no  agglutination  may  occur  until  the 
serum  is  so  far  diluted  that  there  is  only  an  infinitesimal 
amount  of  the  agglutinoid  left  in  the  volume  used  for 
experiment. 

There  is  some  evidence  that  although  agglutination  and 
bacteriolysis  are  separate  processes,  yet  bacilli  are  rendered 
less  virulent  by  agglutination.  Besredka  l  found  this  to  be 
the  case  with  typhoid  bacilli,  animals  being  able  to  with- 
stand larger  doses  of  the  clumped  organisms  than  of  the 
normal  variety.  Bright  and  Temple 3  had  previously 
noted  that  the  bacilli  are  maimed,  but  not  killed,  by  agglu- 
tination. 

It  is  held  by  Ruffer  and  Crendiropoulo 3  that  the 
agglutinating  substances  are  formed  by  the  leucocytes, 
especially  the  multinucleate  variety  generally  associated 
with  inflammation. 

Both  agglutinins  and  bacteriolysins  "  fall  out "  with  one 
of  the  globulin  fractions  when  serum  is  precipitated  with 
ammonium  sulphate.  Thus  the  typhoid  agglutinin  falls  out 
with  the  euglobulin  in  the  serum  of  goats  and  rabbits,  but 
with  the  pseudo-globulin  in  the  serum  of  the  horse. 
Cholera  agglutinin  is  precipitated  with  the  euglobulin  in  the 
serum  of  both  horse  and  goat.4 

Group-reactions. — As  was  noted  previously  in  the 
case  of  the  precipitins,  so  also  with  the  agglutinins,  the 

1  Ann.  de  Flnst.  Pasteur,  1901,  xv.  207. 

2  Brit.  Med.  Journ.,  1897,  i.  206. 

3  Ibid.,  1902,  i.  821. 

4  Pick,  Hofm.  Beitr.,  1901,  p.  384. 


is         SERUMS,    VACCINES,    AND    TOXINS 

reaction  brought  about  is  not  absolutely  specific.  A  pre- 
cipitating serum  may  react  not  only  with  human  albumins, 
for  example,  but  also  with  those  derived  from  apes,  a  nearly 
allied  zoological  order ;  and  a  serum  which  agglutinates,  for 
example  B.  fypho#us,  may  also  cause  clumping  with  a 
culture  of  B.  coli,  a  closely  related  form.  In  both  cases, 
however,  it  is  found  that  the  serum  acts  in  much  greater 
dilutions  upon  the  particular  protein  or  bacterium  respec- 
tively used  for  its  preparation,  than  upon  the  allied  forms. 
Thus  a  serum  prepared  by  inoculation  of  B.  typhosus  may 
agglutinate  this  organism  when  diluted  1  :  1,000,  whereas  it 
may  agglutinate  B.  coli  only  in  a  dilution  of  1  : 50  or  less, 
and  B.  paratyphi  in  dilutions  of  1  :  25  or  under.  This 
phenomenon  is  supposed  to  be  due  to  the  fact  that  the 
bioplasm  of  different  species,  while  consisting  mainly  of 
the  same  substances,  contains  different  proportions  of  these 
constituents.  Nearly  allied  species  will  contain  consider- 
able quantities  of  the  same  protein,  though  in  one  it  may 
be  largely  predominant,  in  others  relatively  less  in  amount. 
Hence  arise  varying  degrees  of  reaction  to  a  serum  con- 
taining an  antibody  to  this  particular  protein. 

Opsonins. — French  observers,  studying  the  phenomena 
of  phagocytosis  under  the  influence  of  Metchnikoff,  early 
discovered  that  the  activity  of  the  leucocytes  was  greater  in 
the  presence  of  serum  than  without  it  (Denys  and  Leclef). 
This  was  confirmed  by  Mennes  and  others.  The  influence 
of  the  serum  has  been  specially  studied  by  Wright  and  his 
collaborators,  the  name  "  opsonins  "  having  been  coined  for 
the  chemical  substances  at  work  (Wright  and  Douglas).1 
Increase  in  rapidity  of  phagocytosis  might  theoretically  be 
brought  about  either  by  an  increase  in  the  voracity  of  the 
leucocytes  or  by  a  diminution  in  the  resistance  offered  by  the 
bacteria  to  their  attack ;  both  processes  have  been  supposed 
to  occur.  The  existence  of  substances  which  increase  the 
activity  of  the  leucocytes  ("  stimulins,"  Metchnikoff,  Leish- 
man)  is  now  doubted  by  most  observers,  the  action  of 
1  Proc.  It.  Soe.  Land.,  1903,  Ixxii.  357  ;  1904,  Ixxiii.  128. 


OPSONINS  19 

opsonins  being  to  render  the  bacteria  either  more  attractive 
(chemiotactic)  or  less  resistant  to  the  phagocytic  cells. 
Some  doubt  has  existed  as  to  the  possibility  of  phagocytosis 
in  the  absence  of  serum,  but  it  seems  to  be  established 
that  it  does  occur,  though  only  to  a  slight  degree.  The 
presence  of  normal  serum  increases  the  activity  of  the 
leucocytes  in  ingesting  all  kinds  of  bacteria;  and  when 
infection  with  a  pathogenic  organism  has  occurred  and 
been  successfully  resisted,  the  opsonic  power  of  the  serum  is 
found  to  be  increased  towards  that  particular  organism.  It 
appears  that  opsonins  formed  in  response  to  the  stimulus 
of  an  infective  organism  are  strictly  specific.  There  seems 
reason  to  hold  that  the  opsonin  of  normal  serum  is  distinct 
from  those  of  "  immune  "  serum,  inasmuch  as  the  former 
is  destroyed  by  heating  the  serum  to  65°  C.  (thermolabile) 
and  is  active  against  many  or  all  kinds  of  bacteria, 
while  the  latter  are  thermostable  and  definitely  specific. 
The  opsonic  power  of  a  serum  rapidly  diminishes  when  it 
is  kept  at  room-temperature,  Knorr l  finding  that  it  is 
reduced  by  one-half  in  twenty-four  hours  and  entirely 
abolished  in  five  days. 

The  exact  nature  of  opsonins  and  their  relation  to  other 
substances  concerned  in  immunity  are  doubtful.  Greig 
Smith2  holds  that  they  are  identical  with  agglutinins. 
Verney  3  believes  that  all  varieties  of  immune  substances — 
complements,  copulas,  antitoxins,  etc. — can  act  as  opsonins. 
Seeing  that  in  a  mixture  consisting  of  serum,  leucocytes, 
and  virulent  and  saprophytic  bacteria  the  leucocytes  ingest 
the  saprophytes  much  more  readily  than  the  parasites,  it  is 
reasonable  to  suggest  that  the  opsonin  acts  by  neutralizing 
the  toxin  or* "  aggressin "  (Bail)  by  which  the  pathogenic 
germ  repels  the  phagocyte.  Griiber  and  Futaki4  regard 
them  as  complements,  owing  to  the  destruction  of  normal 

1  Journ.  Amer.  Med.  Assoe.,  1907,  xlviii.,  No.  15. 

2  Proc.  Linnean  Soc.  N.S.W.,  1905. 

3  Policlin.,  1907,  Sez.  Pract.,  No.  40. 

4  Munch,  med.   Woch.,  1906,  liii.  249. 


20         SERUMS,    VACCINES,    AND    TOXINS 

opsonins  by  heat  (and  their  rapid  disappearance  when  the 
serum  is  kept  is  another  point  of  resemblance).  The 
conA-er.se  of  this  argument  is  used  to  support  the  view 
that  "  immune  "  opsonins  are  really  copulas  (amboceptors), 
since  they  resist  a  temperature  of  60°  C.  But  the 
question  is  at  present  unsettled,  although  the  bulk  of 
the  evidence  appears  to  favour  the  last-mentioned  hypo- 
thesis. Some  chemical  substances,  such  as  formalin, 
chloroform,  and  alcohol,  act  as  "  anti-opsonins,"  diminishing 
phagocytic  activity  (Hektoen).  Anti-opsonins  are  also  said 
to  be  formed  in  cultures  of  bacteria  (Tchistovitch  and 
Jurievitch) : '  these  latter  are  probably  toxins  or  aggressins. 
The  existence  in  opsonins  of  two  groups,  analogous  to 
the  haptophore  and  toxophore  groups  of  a  toxin  (p.  25), 
is  maintained  by  Hektoen  -  and  Kurt  Meyer.3 

Anaphylaxis. — When  the  serum  of  one  species  of 
animal  is  injected  into  an  individual  of  another  species, 
antibodies  are  formed  as  has  already  been  described. 
But  in  addition  to  this  formation  of  antibodies,  or 
as  a  part  of  the  process,  changes  of  a  nature  which 
is  not  understood  take  place  in  the  injected  animal ; 
by  these  it  is  rendered  peculiarly  sensitive  to  a  further 
injection  of  the  same  kind  of  serum.  Symptoms  of 
severe  constitutional  disturbance,  and  sometimes  even 
death,  may  ensue  upon  such  a  second  injection.  Thus, 
if  a  guineapig  receives  an  intraperitoneal  injection  of 
horse-serum,  it  suffers  no  ill  effects ;  but  if  the  injec- 
tion is  repeated  in  about  twelve  days'  time,  it  becomes 
seriously  ill,  with  symptoms  of  collapse,  vomiting,  bloody 
urine  and  faeces,  dyspnrea,  and  convulsions  ;  and  may  die 
rapidly  or  almost  instantaneously  (anaphylactic  shock). 
The  phenomenon  is  called  "  anaphylaxis "  (supersensi- 
bility  or  hypersensibility).  This  condition  does  not  develop 
immediately,  but  only  after  the  lapse  of  a  definite  in- 

1  Eousski  Vratctt,  1908,  rii.  669. 

2  Journ.  Amer.  Med.  A»soc.,  1906,  xlvi.,  No.  19. 
•  Berlin,  klin.  Woch,t  1908,  p.  951. 


PROTECTIVE   FERMENTS  21 

terval  varying  with  the  serum  employed  and  the  animal 
inoculated.  It  may  pass  off  gradually  in  a  month  or 
more,  or  may  persist  for  an  indefinite  length  of  time. 
If  in  the  interval  between  the  first  injection  and 
the  appearance  of  anaphylaxis  another  injection  of  the 
serum  in  question  be  given,  protection  against  the  subse- 
quent development  of  anaphylaxis  is  produced  (anti-ana- 
phylaxis,  Richet) — a  phenomenon  which  has  been  taken 
advantage  of  by  Besredka  in  the  treatment  of  diseases  by 
therapeutic  serums  (see  p.  47).  Apparently  the  increased 
susceptibility  is  connected  in  some  way  with  the  formation 
of  protective  antibodies,  of  which  Richet  considers  it  to 
constitute  the  first  stage.  Milk,  egg-albumin,  bacterial 
proteins,  and  other  substances  are  all  capable  of  inducing 
anaphylaxis.1  The  condition  is  of  interest  as  an  explana- 
tion of  many  cases  in  which  ill  effects  have  followed  the 
use  of  antitoxic  serum  (see  p.  55).  Besredka  2  finds  that 
heating  the  horse-serum  deprives  it  of  toxic  power,  and 
that  if  the  animal  is  anaesthetized  at  the  time  of  the  second 
injection,  no  ill  effects  result. 

Protective  ferments. — Very  closely  related,  in  all 
probability,  to  the  phenomena  of  anaphylaxis  is  the  dis- 
covery of  Abderhalden  that  the  presence  of  minute  amounts 
of  any  foreign  or  unusual  protein  in  the  blood-stream  of 
a  living  animal  gives  rise  to  the  formation  of  a  specific 
ferment  capable  of  breaking  up  this  particular  protein  into 
simpler  bodies  resembling  the  products  of  digestion.  This 
property  of  ferment-formation  is  active  not  only  against 
proteins  derived  from  other  species  of  animals,  but  also 
against  the  products  of  the  cells  of  the  animal's  own 
economy.  So  that  in  pregnancy  ferments  are  formed 
capable  of  breaking  down  placental  tissue,  small  quantities 
of  which  enter  the  maternal  circulation ;  and  in  conditions 

1  Rosenau  and  Anderson,  Bull.  Pub.  Health  and  Mar.  Hasp.  Serv. 
U.S.A.,  1907,  No.  30  ;  1906,  No.  29;  and  1909,  No.  50. 

2  Compt.  Rend.  Soc.  Biol,  1907,  Ixii.  1053.     See  Richet,  Ann.  de 
I'lnst.  Pasteur,  1907,  xxi.  497. 


22         SERUMS,   VACCINES,    AND    TOXINS 

of  disease,  when  the  cells  of  certain  tissues  undergo 
destruction,  ferments  are  recognizable  which  act  only  on 
the  proteins  of  these  particular  cells.  Possibly  similar 
ferments  are  formed  against  foreign  carbohydrates  and  fats, 
but  this  does  not  appear  to  be  so  certain.  This  peculiar 
property  of  forming  special  ferments  capable  of  destroying 
(catalysing)  foreign  proteins  appears  to  be  protective  in 
character,  the  cells  of  the  tissues  being  thus  saved  from 
any  prolonged  contact  with  abnormal  constituents  of  the 
serum ;  these  are  broken  down  into  those  simpler  "  cleavage 
products  "  which  are  common  to  all  proteins  aud  are  suitable 
for  use  by  the  cells  as  building  materials  to  be  recombined 
in  their  own  protoplasm. 

Ehrlich's    theory   of    immunity.  —  Having    thus 

briefly  sketched  the  peculiar  properties  which  are  conferred 
on  the  blood-serum  by  contact  with  bacteria  and  other 
bodies,  it  remains  to  consider  the  theory  of  the  production 
of  immunity  and  allied  phenomena  which  at  present  holds 
the  field.  This  is  due  to  Ehrlich,  and  is  known  as  his 
"  side-chain  "  hypothesis.  The  name  is  taken  from  organic 
chemistry,  in  which  complex  molecules  have  the  property 
of  picking  up  and  combining  with  other  atom-groups. 
Thus  in  the  example  given  in  Fig.  5  we  see  that  a  benzene 
nucleus  has  joined  to  itself  three  NO.,  groups  and  one  OH 
group,  becoming  trinitro-benzene  or  picric  acid. 

The  chemical  processes  which  occur  in  living  protoplasm 
are,  of  course,  much  more  complicated  than  those  of  in- 
organic matter.  Instead  of  a  comparatively  simple  change 
brought  about  once  and  for  all,  as  in  the  interaction  of 
two  simple  salts,  or  the  rather  more  complex  phenomena 
of  organic  chemistry,  we  have  a  continual  series  of  changes 
taking  place  between  a  mass  of  protoplasm  and  the  sur- 
rounding lymph.  The  molecule  of  living  matter  is  itself 
vastly  complex.  We  know  that  it  can  break  down  into  a 
number  of  simpler  substances,  such  as  albumin,  globulin, 
polypeptides,  lecithin,  etc.,  each  of  which  is  in  reality  a 
complex  body,  yet  all  of  which  are  loosely  or  tightly  bound 


SIDE-CHAIN    THEORY 


23 


together  into  a  huge  molecule  of  protoplasm.  Of  the 
true  nature  of  this  last  we  have  no  real  knowledge.  For 
the  purpose,  however,  of  forming  a  mental  picture  of 
the  chemical  processes  taking  place  in  living  matter,  we 
may  imagine  the  cell  as  consisting  of  a  central  mass — 
corresponding  with  the  ring  of  a  benzene  molecule — to 
which  are  united  outlying  groups  of  molecules  that  have 
the  power  of  entering  into  combination  with  other  sub- 
stances circulating  in  the  lymph,  such  as  particles  of 
food,  etc.  These  outlying  groups  are  the  "side-chains" 
of  Ehrlich's  theory.  Thus  a  side-chain  attached  to  a  cell 


HC 


CH 

A 


COH 


HC 


CH 


V 

CH 

Benzene 


CH 


NO,C^,       NCNO? 


CH 


CN02 

Tri  nit  ro-  benzene 
Fig.  5. 


may  join  to  itself  a  particle  of  oxygen,  of  carbohydrate, 
of  fat,  etc.,  and  thereby  take  part  in  the  nourishment 
of  the  cell ;  or  it  may  become  united  with  a  molecule  of 
poison,  such  as  the  toxin  of  the  diphtheria  bacillus.  In 
the  latter  case,  either  of  two  things  may  conceivably 
happen  :  the  toxin  may,  through  the  medium  of  the  side- 
chain,  become  part  of  the  whole  cell  and  may  thus  poison 
it,  producing  actual  death  (necrosis)  or  degeneration  (e.g. 
cloudy  swelling) ;  or  it  may  cause  the  death  only  of  the 
individual  side-chain  to  which  it  lias  attached  itself,  in 
which  case  the  latter  is  thrown  off  and  a  new  one  is 
formed  by  the  cell.  This  reproductive  process  is  supposed 
to  represent  what  takes  place  in  the  presence  of  only  a 
small  quantity  of  poison,  such  as  first  reaches  the  cell  in  a 
case  of  disease. 


24         SERUMS,    VACCINES,    AND   TOXINS 

The  side-chains  of  living  cells,  in  virtue  of  their  pro- 
perties of  taking  up  food  and  other  materials — useful  and 
harmful — from  the  lymph,  are  known  as  receptors. 

By  way  of  illustration  of  the  working  of  this  hypothesis 
we  may  take  the  process  of  haemolysis,  as  it  affords  perhaps 
the  easiest  example.  Here,  as  we  saw  above  (p.  10),  two 
substances,  (a)  and  (6),  are  necessaiy  to  effect  destruction  of 
the  corpuscle.  Ehrlich's  theory  supposes  that  the  proto- 
plasm of  the  corpuscle  has  not  the  power  of  combining 
directly  with  the  dissolving  substance  (complement)  which  is 
always  present  in  serum,  but  that  it  can  attach  to  itself  a 
second  body  (copula),  produced  in  immunized  animals,  which 


A  B  D 

Fig.  6. — Diagrammatic  representation  of  haemolysis  (or  cytolysis).  A, 
Corpuscle  or  cell,  consisting  of  molecules  of  different  sizes,  with 
special  groups  (side-chains,  receptors)  at  the  periphery.  B,  Molecules 
of  complement.  C,  Copula  or  immune  body.  D,  Corpuscle  with 
complement  molecules  attached  to  side-chains  by  copula. 

in  its  turn  can  grapple  to  itself  the  solvent ;  and  that  thus  the 
destructive  matter  is  enabled  to  combine  with  the  corpuscle 
and  dissolve  it.  This  process  is  illustrated  in  Fig.  6. 

An  exactly  similar  process  is  at  work  in  bacteriolysis  ; 
the  ferment  present  in  the  serum  being  attached  to  the 
bacteria  by  a  copula,  immune  body,  or  bacteriolysin,  which 
is  itself  a  side-chain  thrown  off  from  some  of  the  tissue- 
cells. 

The  process  by  which  a  bacterial  toxin  acts  on  a  cell, 
though  at  first  sight  more  direct,  is  found  to  be  very  simi- 
lar to  the  action  of  a  hjemolytic  substance  on  a  corpuscle ; 
only  the  toxin  consists  of  both  destructive  substance 


FORMATION   OF    ANTITOXIN  25 

and  uniting  substance  joined  together  in  one  molecule. 
The  two  parts  in  this  case  are  called  respectively  the 
toxophore  and  the  haptophore  (roZtKov,  poison ;  <j>tpM,  I 
carry :  and  OLTTTU,  I  join ;  0£/>w,  I  carry),  the  latter  corre- 
sponding to  the  copula.  The  combined  toxic  molecule 
seizes  on  an  appropriate  side-chain  of  a  cell ;  and  if  a 
number  of  side-chains  thus  take  up  poisonous  groups, 
the  cell  itself  dies.  If  only  one  or  two  side-chains  are 
thus  attacked,  they  are  themselves  killed  and  drop  off,  but 
the  cell  escapes.  The  uninjured  portion  of  the  bioplasm 
then  proceeds  to  put  out  a  fresh  supply  of  the  particular 
kind  of  side-chains,  of  which  some  have  been  killed. 
As  frequently  happens  in  living  bodies,  the  repair  goes 
beyond  the  original  supply  (according  to  Weigert's  "  Over- 
production Theory  "),  and  the  cell  thus  becomes  furnished 
with  an  increasing  number  of  the  side-chains  capable 
of  fixing  the  particular  toxin. 

But  as  this  process  goes  on  the  cell  forms  so  many 
side-chains  that  it  cannot  keep  them  all  attached  to  itself, 
and  some  of  them  are  cast  off  into  the  lymph  around  the 
cell  and  ultimately  get  into  the  blood.  These  free  side- 
chains  constitute  the  antitoxin.  They  are  capable  of 
uniting  with  the  molecules  of  the  toxin  before  it  reaches 
the  cells,  and  in  this  way  they  prevent  any  poisonous 
action  resulting.  Further,  if  the  serum  containing  these 
free  side-chains  is  injected  into  another  animal,  they  will 
still  perform  the  same  office  under  their  new  conditions, 
and  will  confer  on  the  second  animal  the  same  immunity  as 
was  possessed  by  the  original  immunized  one.  The  curative 
and  prophylactic  action  of  antitoxin  is  thus  explained 
(see  Fig.  7).  If  we  add  to  some  toxin  an  equivalent 
quantity  of  antitoxin,1  the  molecules  of  poison  present 

1  Properly  speaking,  antitoxin  is  the  actual  substance  which 
combines  with  the  toxin  and  neutralizes  it.  In  ordinary  parlance 
the  word  is  used  for  the  serum  containing  the  antitoxic  body.  For 
further  consideration  of  the  interaction  of  toxin  and  antitoxin,  set 
p.  101. 


26         SERUMS,    VACCINES,    AND   TOXINS 

become  combined  with  the  free  side-chains  in  the  anti- 
toxin, and  can  no  longer  attack  the  tissue-cells.  Hence 
the  injection  of  a  mixture  of  the  two  is  innocuous.  If  the 
bacteria  have  already  gained  a  footing  in  the  patient  and 
are  pouring  out  constantly  a  stream  of  toxin,  the  injection 
of  a  dose  of  antitoxin  neutralizes  the  poison  ;  but  it  is 
necessary  to  give  a  very  large  dose  of  it  in  order  to  meet 
the  continuous  inflow  of  toxin.  If,  on  the  other  hand,  a 
person  has  not  yet  got,  say,  diphtheria,  but  is  exposed  to 
the  chance  of  infection,  then  a  protective  dose  of  antitoxin 


Fig.  7. — Diagram  of  cell  with  numerous  side-chains  (receptors)  produced 
by  stimulation  with  toxin.  Some  of  these  have  been  cast  off  as 
antitoxin,  and  are  combining  with  molecules  of  toxin.  On  the  left 
are  seen  molecules  of  toxin,  showing  t,  toxophore,  and  h,  hapto- 
phore,  elements. 

may  be  given  to  anticipate  infection — so  as  to  be  lying  in 
wait,  as  it  were,  for  any  poison  that  may  be  formed. 

To  this  last  application  it  might  be  objected  that,  as 
previously  stated,  the  antitoxin  is  not  antibacterial,  and 
that  therefore  it  does  nothing  to  stop  infection.  But  as 
the  bacilli  conduct  their  conflict  with  the  body  by  means  of 
their  poisons,  injuring  the  cells,  and  so  preventing  them  from 
forming  antibacterial  matter,  the  neutralization  of  the  first 
doses  of  poison  enables  the  organism  (the  animal  attacked) 
to  gain  time  to  form  its  defensive  weapons.  To  use  a 
military  simile,  we  may  do  much  to  resist  the  first  assault 
if  we  can  damp  the  powder  of  our  antagonists,  and  so  we 
may  enable  our  own  reinforcements  to  come  into  action. 


ACTION   OF    ANTITOXIN  27 

It  is  important  to  remember  that  by  administering 
antitoxin  we  only  neutralize  the  free  toxin  present.  That 
which  has  already  entered  into  combination  with  the  side- 
chains  of  the  tissue-cells  is  practically  beyond  the  reach  of 
the  remedy.  It  is  possible  that,  if  there  is  a  very  large 
quantity  of  antitoxin  present,  some  kind  of  "  mass  "  action 
may  take  place,  whereby  the  toxin  may  be  withdrawn 
from  its  combination  with  the  cells  and  caused  to  combine 
with  the  antitoxin  instead ;  but  this  is  not  absolutely 
certain.  Hence  arises  the  urgent  need,  in  giving  antitoxin, 
to  give  it  as  early  as  possible  in  the  disease.  For  example, 
in  the  case  of  tetanus,  it  may  be  too  late  to  make  use  of 
antitoxic  serum  when  the  symptoms  of  the  disease  have 
appeared,  the  poison  being  already  closely  attached  to  the 
cells;  hence  many  failures  and  much  disappointment  in 
the  treatment  of  this  disease. 

It  may  be  pointed  out  that  so  long  as  the  side-chains 
are  attached  to  the  cells  they  are  a  source  of  weakness,  as 
enabling  the  toxins  to  attack  them,  whereas,  when  they 
are  cast  off  into  the  serum  as  antitoxin,  they  become  a 
protection.  A  toxin  can  only  act  if  it  finds  appropriate 
receptors  to  which  it  can  attach  itself;  otherwise  it  would 
circulate  harmlessly  in  the  lymph.  Since  it  would  be  better 
for  the  cell,  from  the  point  of  view  merely  of  its  relation 
with  toxins,  if  it  had  no  side-chains,  it  is  supposed  that 
these  exist  originally  for  some  other  purpose ;  and  this  is 
considered  to  be  the  assimilation  of  nutritive  materials,  as 
already  suggested.  These  presumably  are  taken  up  by  the 
cell,  in  the  same  manner  that  toxins  are  attached,  by  means 
of  the  affinities  possessed  by  the  side-chains. 

A  distinction  ,is  held  to  exist  between  the  toxins  formed 
by  bacteria  on  the  one  hand — and  with  them  must  be 
grouped  the  poisons  elaborated  by  poisonous  snakes,  and 
those  resident  in  certain  plants,  such  as  ricin,  abrin,  etc. — 
and  the  ordinary  mineral  and  vegetable  poisons — mercury, 
arsenic,  strychnine,  morphine,  and  the  like.  It  is  supposed 
that  the  substances  which  form  the  first  group  are  proteid 


28         SERUMS,    VACCINES,    AND   TOXINS 

in  character  (globulins,  etc.),  and  that  it  is  towards  them 
especially  that  the  side-chain  activity  of  the  cell  is  directed. 
They  are  capable  of  acting  as  antigens  (p.  12).  The 
poisons  of  the  second  group  appear  to  act  differently,  as 
in  the  case  of  these  substances  no  antitoxic  serum  can  be 
prepared.  The  cell  as  a  whole  is  either  killed  or  recovers 
from  the  effects  of  the  poison,  but  it  cannot  protect  itself 
by  throwing  off  side-chains  to  neutralize  the  poison.  This 
property  is  distinct  from  the  power  which  the  body  un- 
doubtedly possesses  of  accustoming  itself  to  increasing  doses 
of  a  poison  such  as  morphine  or  arsenic.  Nevertheless,  even 
in  the  case  of  such  a  poison  as  arsenic,  absorption  by  means 
of  receptors  has  been  supposed  to  take  place,  and  Ehrlich 
believes  that  certain  chemical  groups,  such  as  acetyl,  have 
the  property  of  acting  as  copulas  and  attaching  the  poison 
to  the  living  cell,  in  virtue  of  the  aftinity  between  these  and 
the  organic  radical  in  question.  (See  also  Chapter  xxi., 
p.  412,  Chemotherapy.) 

Incubation  period.— A  peculiar  feature  in  the  action 
of  bacterial  toxins  i.s  the  occurrence  of  an  incubation 
period  between  the  administration  of  the  dose  and  the  onset 
of  symptoms.  Thus,  by  giving  increasing  doses  of  tetanus 
toxin,  the  rapidity  of  the  onset  of  spasm  may  be  increased 
up  to  a  certain  point ;  but  after  this  is  reached,  no  further 
addition  of  poison  will  accelerate  the  event.  It  may  be 
suggested  that  time  is  needed,  not  only  for  the  combination 
of  the  toxin  with  the  side-chains — which  is  probably  a 
somewhat  slow  process — but  also  for  the  absorption  of  the 
poisoned  receptor  into  the  general  body  of  the  cell,  which 
must  precede  symptoms  of  intoxication. 

Before  leaving  this  subject  it  may  be  well  to  emphasize 
the  fact  that  the  explanation  given  by  Ehrlich  of  the 
phenomena  of  bacteriolysis,  the  action  of  toxins,  etc.,  is 
pure  hypothesis.  The  hypothesis  has  been  fruitful,  sug- 
gesting new  lines  of  research;  and  so  far  the  results  obtained 
are  mainly  consistent  with  the  theory.  But  care  must 
be  taken  not  to  confuse  the  fascinating  diagrams  by  which 


FORMS    OF    IMMUNITY  29 

we  are  enabled  to  form  a  mental  picture  of  the  events 
that  take  place,  with  realities.  An  antitoxin  is  probably 
analogous  to  a  secretion,  and  the  process  of  bacteriolysis  is 
a  chemical  reaction  into  which  three  bodies  enter — very 
similar  to  the  interaction  of  the  fibrin  ferment,  fibrinogen, 
and  calcium  salts  to  form  actual  fibrin.  In  the  present 
account  the  illustrations  have  been  kept  as  diagrammatic 
as  possible,  at  the  expense  of  verisimilitude  and  artistic 
merit,  in  order  to  avoid  any  undue  pretence  to 
reality. 

We  have  thus  seen  that  the  serum  of  an  "  immunized  " 
animal  may  contain  not  only  antitoxic  substances  capable 
of  neutralizing  the  poisons  of  bacteria,  and  antibacterial 
bodies  (complement  and  copida)  fitted  to  destroy  the 
organisms,  but  also  substances  which  sensitize  bacteria 
(opsonins)  or  which  agglutinate  bacteria  or  corpuscles 
(agglutinins),  others  which  destroy  living  cells  (cytolysins), 
and  others  still  which  cause  a  precipitate  with  the  albumins 
of  the  serum  of  other  species  (precipitins). 

Forms  of  immunity. — It  remains  to  explain,  on  the 
theories  just  set  forth,  the  various  forms  of  immunity 
already  alluded  to.  In  the  case  of  species,  races,  or 
individuals  who  are  naturally  immune  to  certain  infec- 
tions, we  must  suppose  either  that  they  possess  no  side- 
chains  capable  of  uniting  with  the  toxins  of  the  bacterium 
causing  the  disease,  the  latter  thus  becoming  harmless,1 
or  that  they  normally  contain  in  their  systems  the  two  sub- 
stances necessary  to  repel  the  bacteria,  viz.  the  complement 
and  the  copula.  A  further  possibility  may  be  considered, 
arising  from  the  peculiar  quality  of  poisons  by  virtue  of 
which  they  injuriously  affect  only  certain  tissues.  Thus, 

1  An  instance  of  this  condition  may  be  seen  in  the  tortoise,  which 
is  immune  to  the  toxins  of  tetanus  ;  if,  however,  the  blood  of  a  tor- 
toise which  has  received  a  dose  of  tetanus  toxin  be  injected  into  a 
susceptible  animal,  it  will  cause  death,  showing  that  the  poison  is  not 
neutralized  in  any  way,  but  merely  has  no  power  of  affecting  the 
cells  of  the  tortoise. 


30         SERUMS,    VACCINES,    AND    TOXINS 

morphine  acts  on  the  cells  of  the  brain,  phosphorus  on  the 
liver,  diphtherial  toxin  on  the  cardiac  muscle  and  peri- 
pheral nerves,  tetanus  chiefly  on  the  spinal  cord.  If  in 
any  individual  there  are  cells  of  other  tissues  which  hav/> 
greater  affinity  for  a  toxin  than  have  those  cells  which 
it  possesses  the  power  of  injuring,  the  former  may  absorb 
the  poison — with  impunity — and  leave  none  to  cause 
symptoms  of  poisoning.  In  those  who  are  artificially 
immunized  or  who  have  recovered  from  a  disease  (acquired 
immunity)  a  bacteriolytic  copula  has  been  produced,  as  has 
been  described  (along  with  opsonins,  agglutinins,  etc.),  by 
gradual  education  of  the  cells  to  throw  it  off,  or  a  power  of 
forming  antitoxin  has  been  similarly  acquired.  In  all  these 
cases  the  immunity  is  said  to  be  "  active."  When  an  animal 
has  received  into  its  system  a  dose  of  antibacterial  or  anti- 
toxic serum  and  is  thereby  enabled  to  resist  a  disease,  it  is  said 
to  possess  "  passive  "  immunity.  This  lasts  only  as  long  as  the 
injected  serum  remains  in  the  body ;  and  this  is  not,  as  a 
rule,  for  any  long  period  of  time,  since  the  foreign  serum  is 
more  or  less  rapidly  excreted.1  The  animal  in  this  latter 
case  has  not  gained  for  itself  any  power  of  forming  pro- 
tective substances  ;  whereas  in  active  immunity  its  cells 
have  been  educated  to  perform  this  duty,  and  this  acquire- 
ment seems  to  be  retained  either  permanently  or  for  a  con- 
siderable period  of  time.  <  It  is  found  that,  if  an  individual 
has  gained  this  active  immunity  to  one  disease  and  then 
becomes  infected  with  a  second  distinct  malady,  the  former 
protective  power  is  often  lost. 

Welsh  has  suggested  that  in  cases  of  infection  a  con- 
flict may  be  supposed  to  occur  between  a  bacterium  and 
the  body-cells,  each  side  replying  to  the  destructive  sub- 
stances brought  against  it  by  its  opponent,  with  antibodies 
capable  of  neutralizing  them — toxin  being  met  by  anti- 

1  The  antitoxin  or  copula  injected  may  perhaps  be  neutralized  by 
the  formation  of  an  anti-antitoxin  or  anti-copula,  and  not  merely 
passed  out  of  the  body ;  or  it  may  be  broken  up  by  a  special  ferment, 
as  are  other  foreign  proteins  (p.  21). 


MODIFICATION    BY   TISSUES  31 

toxin,  bacteriolysin  by  antibacteriolysin,  and  so  forth. 
Enough  has  been  said,  at  any  rate,  to  show  the  immense 
complexity  of  the  serum,  and  the  capacity  possessed  by 
animal  bodies  of  protecting  themselves  in  many  ways 
against  injurious  influences. 

Modification  of  phenomena  of  bacteriolysis,  etc., 
in  the  presence  of  living  tissues. — It  might  seem  from 
a  consideration  of  the  foregoing  facts  that  the  explanation 
of  immunity  was  fairly  simple,  but  other  ascertained 
facts  render  the  question  more  complicated.  Thus,  taking 
the  case  of  anthrax  bacilli,  we  find  that  the  blood  of  the 
rabbit,  a  highly  susceptible  animal,  acts  destructively  upon 
the  organisms  in  a  test-tube  :  within  the  body  it  manifestly 
does  not  do  so.  Similarly,  all  white  rats  possess  serum  which 
destroys  anthrax  bacilli,  but  they  are  not  all  immune.  On 
the  other  hand,  the  serum  of  animals  immune  to  the  dis- 
ease, as  that  of  the  hen,  forms  a  good  culture-medium  for 
the  bacillus.  It  thus  becomes  clear  that  we  have  to  take 
into  account  not  only  the  blood,  but  also  the  living  tissues 
by  which  it  is  surrounded  in  the  body.  In  the  one  case  the 
tissues  seem  to  exercise  some  inhibitory  influence  over  the 
bacteriolytic  action  of  the  blood  ;  in  the  other,  they  supply 
some  factor  necessary  for  the  defence  of  the  animal  against 
the  bacilli.  Further  experiments  show  that  while  the 
serum  of  the  rabbit  is  destructive  for  anthrax  bacilli,  an 
extract  of  its  organs  prepared  by  triturating  them  with  salt 
solution  has  no  such  power.  Indeed,  if  crushed  organs  are 
added  to  the  serum  and  the  bacilli  exposed  to  the  action  of 
the  mixture,  no  bacteriolysis  takes  place.  The  tissue-cells 
have  in  some  way  deprived  the  serum  of  its  bacteriolytic 
property. 

The  explanation *  that  is  given  of  these  phenomena  is  as 
follows  :  We  have  already  seen  that  a  copula,  or  immune 
body,  is  needed  to  fasten  the  ferment  to  the  bacteria  and  so 
produce  their  destruction.  This  copula  has  affinity  for  the 
tissue-cells — in  this  case  an  even  greater  affinity  than  it  has 
1  Bail,  Proffer  med.  Woch.,  Nov.  25,  1903,  p.  307. 


32         SERUMS,    VACCINES,    AND    TOXINS 

for  the  bacilli — -hence  it  unites  with  the  cells,  and  is  no 
longer  available  for  the  process  of  bacteriolysis. 

Maternal  transmission  of  immunity. — The  ques- 
tion of  the  transmission  of  immunity  from  mother  to  off- 
spring is  one  of  considerable  interest,  but  is  not  yet  satis- 
factorily elucidated.  Agglutinating  power  is  not  usually 
transmitted  in  the  case  of  enteric  fever,  nor  in  tuberculosis  ; 
but  occasionally  such  transference  is  found.1  Haeniolysins 
are  transmissible  in  animals  (Kreidl  and  Mandl),2  and 
immunity  to  diphtherial  toxin  (six  out  of  twelve  guinea- 
pigs,  Anderson) : 5  so  too  is  supersensibility  to  horse-serum, 
according  to  this  last  observer.  Immune  bodies  of  different 
kinds  may  pass  into  the  milk  :  thus  Courmont  and  Cade  * 
found  that  agglutinins  were  ti-ansferred  to  an  infant  through 
the  milk  of  a  wet-nurse,  and  Salge  '  finds  that  diphtherial 
antitoxin  may  be  so  transmitted  and  absorbed  by  the 
infant.  According  to  v.  Eisler  and  Sohma,6  opsonins  are  not 
transmitted  by  the  mother  to  the  fa-tus  in  utero,  but  they 
are  present  in  the  milk.  In  all  these  cases  the  pi-operties 
conferred  are  merely  passive  and  are  soon  lost  by  the 
offspring.  The  father,  as  might  be  expected,  has  no  power 
of  transmission  of  immunity  (Remlinger)." 

Absorption    of  toxins   and   antitoxins   by   the 

moilth.— Closely  allied  to  the  question  of  maternal  trans- 
mission of  immunity  is  that  of  the  absorption  of  antibodies 
when  administered  by  the  mouth.  Hewlett 8  found  that 
diphtherial  antitoxin  administered  by  the  mouth  was 

1  Rodhain,  Prayer  med.  Woch.,  1903,  iii.,  Hft.  3. 

-  IHen.  Win.  Jf'och.,  1904,  No.  22,  p.  611. 

s  Bull.  Hyg.  Lab.    U.S.  Pub.  Health  and  Mar,  Hosp.  Sen:,  1906, 
No.  30. 

4  Compt.  Rend.  Soc.  SioL,  Nov.  25,  1899. 

5  Jahrb.f.  KinXerheillc.,  1904,  Ix.  1. 

6  Wien.  klin.  Woch.,  1908,  No.  19. 

7  Ann.  de  VInst.  Pasteur,  1899,  xiii.  189.     See  aho  Merkel,  Munch, 
toed,  iroch.,  Feb.  23,  1904,  p.  329;  Covazza,  I!  Polictin.,  Mar.  5,  1903  ; 
Bertarelli,  Centralbl.f.  Bakt.,  1906,  Orig.,  xli.  767. 

*  Lancet,  1902,  i.  375  (Proc.  Path.  Soc.  Land.}. 


SOURCE   OF   ANTIBODIES  33 

useless  in  protecting  animals  against  the  poison  of  the 
disease,  and  this  is  confirmed  by  Salge,1  who  finds,  however, 
that  any  antitoxin  present  in  the  mother's  milk  is  absorbed. 
If  this  is  confirmed,  it  opens  up  an  interesting  question  in 
proteid  digestion ;  for  it  is  usually  held  that  proteins  are 
broken  up  into  their  constituent  ammo-acids  and  other 
bodies  in  the  process  of  digestion  and  re-synthesized  in 
the  system.  Diphtherial  antitoxin  is  probably  a  complex 
proteid  body  and  suffers  the  same  fate  ;  but  it  would  seem 
that  the  proteins  in  mother's  milk,  being  closely  related  to 
or  identical  with  those  of  the  child,  may  be  absorbed  intact. 
Toxins  given  by  the  mouth  (e.g.  tuberculin)  are  said  by 
some  observers  to  be  absorbed,  but  according  to  Ransom  ~ 
and  to  Tchitkine 3  the  toxins  of  diphtheria  and  tetanus 
do  not  enter  the  system  by  this  route.  Further  experi- 
ments are,  however,  necessary  in  regard  both  to  this  and 
to  other  toxins,  as  McClintock  and  King  *  state  that  in 
rabbits  some  absorption  of  antitoxin  occurs  from  the 
alimentary  canal,  arid  that  this  may  also  occur  in  man ; 
while  Onorato  5  states  that  similar  absorption  takes  place 
in  the  guineapig,  the  antitoxin  being  recognizable  in  the 
blood  within  twelve  hours,  and  present  for  over  a  fortnight. 
Vaccines  (i.e.  dead  bacilli)  given  by  the  mouth  are  said  by 
some  observers  to  exert  the  same  immunizing  effect  as 
when  administered  subcutaneously ;  a  suggestion  vigorously 
contradicted  by  others.  Here  again  further  evidence  is 
needed.6 

Source  Of  antibodies. — With  regard  to  the  site  of 
production  of  the  complement  or  alexine,  there  is  some  evi- 
dence that  the  leucocytes  constitute  at  least  one  source 

1  Op.  supra  cit. 

2  Deut.  med.  Woch.,  1898,  p.  117. 

3  Ann.  de  VInst.  Pasteur,  1905,  xix.  335. 

4  Journ.  Infect.  Bis.,  1906,  iii.  701. 

8  Ann.  1st.  Maraffliano,  Geneva,  1904,  i.  159. 

6  See  Loeffler,  "  Itnmunisierung  per  Os,"  Berlin,   1906.    Wright, 
Lancet,  1908,  ii.  232.    Also  infra,  p.  117. 


34         SERUMS,    VACCINES,    AND    TOXINS 

of  such  bodies.  Thus,  dog's  serum  alone  is  found  not  to 
act  bacteriolytically  on  anthrax  bacilli,  but  if  some  leuco- 
cytes from  the  same  animal  are  added  to  the  serum,  then 
destruction  of  the  bacilli  takes  place.  From  other  data 
it  is  believed  that  the  serum  of  dogs  contains  the  immune 
body,  so  that  it  appears  that  in  this  case  the  leucocytes  are 
the  source  of  the  complement  (Briscoe).1  This  view,  cor- 
responding with  that  of  Metchnikoff,  has  recently  been 
disputed  owing  to  the  fact  that  leucocytes  seem  to  have 
the  power  of  absorbing  complement  from  fluids  containing 
it  (Hoke).2  In  other  cases  it  has  been  possible  to  supply 
the  complement  by  the  addition  of  an  extract  of  the  tissues, 
so  that  these  also  must  be  regarded  as  forming  ferments 
capable  of  acting  bacteriolytically  in  the  presence  of  a  suit- 
able copula. 

Complement  is  not  normally  present  in  cerebro-spinal 
fluid,  nor  is  there  any  in  oedema  fluid  or  in  purulent 
exudates,  but  it  is  found  in  inflammatory  exudates  which 
are  not  purulent,  in  the  fluid  of  blisters,  and  so  forth 
(Muttermilch  and  Hertz).3  Gurd  4  states  that  there  is  no 
free  complement  in  plasma,  but  only  a  forerunner  or 
"  complementogen." 

Of  the  chemical  nature  of  complement  nothing  is  known  ; 
indeed,  no  antibody  has  ever  been  isolated  and  identified. 
Complement  is  usually  regarded  as  being  allied  to  the  fer- 
ments or  enzymes — an  equally  unknown  chemical  group. 
Ferrata  5  found  that  it  was  separable  into  two  parts,  one  of 
which  fell  out  with  the  globulin  of  the  serum  (Mittelstiick), 
while  the  other  i-emained  in  solution  with  the  albumin 
(Endstiick),  Neither  part  alone  is  active,  but  on  mixture 

1  Prof.  Orth's  "Festschrift"  (Berlin,  1903),  p.  396  ct  seq.  ;   see 
Brit.  Mtd.  Journ.  Epit.,  June  27,  1903,  p.  104. 

2  Quoted  by  Kaplan,  "Serology  of  Nervous  and  Mental  Diseases,'' 
1914. 

3  Zeitschr.  f.  klin.  Med.,  1912,  p.  404. 

4  Journ.  Infect.  l)is.,  1914,  xi.  142. 

5  Berl.  /••/(«.  Woeh.   1907,  p.  366. 


SOURCE   OF   ANTIBODIES  35 

of  the  two  the  power  of  acting  as  complement  is  regained, 
though  not  to  the  original  extent. 

It  is  generally  held  that  other  antibodies  are  formed 
in  the  hretnopoietic  system — the  spleen,  lymphatic  glands, 
bone-marrow — or  even  in  the  blood-stream  itself.1 

Copula  may  possibly  be  derived  from  leucocytes,  as  Eyre2 
found  a  general  correspondence  between  opsonin  formation 
and  leucocytosis  in  pneumonia.  Allen  has  adduced  some 
evidence  that  thermostable  antibodies  are  formed  in  the 
muscle-cells.  Hektoen  and  Carlson 3  found  that  toxin 
rapidly  disappeared  from  the  circulating  blood  of  an  animal, 
and  that  this  blood  was  not  capable  of  giving  rise  to 
formation  of  antitoxin  if  injected  into  another  animal. 
But  if  the  first  animal  which  had  received  the  toxin  was 
bled  and  transfused  with  the  blood  of  a  normal  animal,  the 
formation  of  antitoxin  still  went  on,  showing  that  the 
toxin  had  been  fixed  by  the  tissues  and  that  the  formation 
of  antitoxin  continued  in  them. 

The  quantity  of  antibodies  present  in  the  serum  is  said 
to  be  indicated  by  the  amount  of  globulin  precipitated  on 
dropping  dilute  acetic  acid  into  diluted  serum  or  blood 
(Rivalta's  reaction) ;  it  is  also  stated  to  correspond  with 
the  degree  of  leucocytosis  present  in  infective  conditions 
(Gironi).4 

The  formation  of  antibodies  is  stimulated  by  the 
occurrence  of  haemorrhage  or  by  fever  ;  also  by  injection  of 
small  doses  of  mercuric  chloride,  which  acts  as  a  proto- 
plasmic poison  (Kalledey). 8 

Plurality  Of  Complements.— Considerable  contro- 
versy has  centred  round  the  question  whether  the  com- 

1  For  literature  see  Reiter,  Zeitschr.  f.   Immunitdtsforsck.,  1913, 
Orig.,  xviii.  5. 

2  Lancet,  1908,  i.  539. 

»  Journ.  Infect.  Vis.,  1910,  vii.  319. 

4  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u,  Chir.,  1912,  xxv.  229.     Of .  Eyre, 
op.  supra  cit. 

5  Centralbl.  f.  Bdkt.,  Ixviii.  358. 


36         SERUMS,    VACCINES,    AND    TOXINS 

plenieuts  or  alexines,  by  which,  for  example,  bacteriolysis 
is  brought  about,  are  the  same  for  all  micro-organisms, 
and  the  same  in  all  species  of  animals.  Thus,  it  might  be 
possible  to  prepare  an  immune  serum  (one  containing  a 
copula  or  intermediary  body)  which  should  be  capable  of 
immunizing  a  certain  species  of  animal  (A)  against  a 
particular  bacillus,  but  this  intermediary  body  might  only 
be  capable  of  uniting  to  the  bacilli  a  special  form  of  com- 
plement such  as  exists  in  the  kind  of  animal  (A)  used.  We 
cannot  be  certain  without  making  the  actual  experiment 
that  it  will  act  in  the  same  manner  within  the  body  of  a 
second  species  of  animal  (B)  :  it  may  be  incapable  of  uniting 
with  the  form  of  complement  which  is  here  present.  For 
example,  we  might  prepare  an  antityphoid  serum  capable 
of  protecting  an  animal  (say,  horse)  against  typhoid  bacilli, 
i.e.  of  causing  destruction  of  JJ.  typhosus  when  it  is  in- 
jected into  this  animal ;  but  it  does  not  necessarily  follow 
that  it  will  act  as  a  cure  in  cases  of  enteric  fever  in  man, 
since  human  beings  may  not  possess  the  kind  of  comple- 
ment with  which  horse-copula  can  unite  so  as  to  attack 
the  micro-organisms. 

It  has  also  been  a  moot  point  whether  in  a  single 
species  of  animal  there  is  present  only  one  complement, 
which  is  ready  to  act  upon  all  bacteria  alike,  and  upon 
blood-corpuscles,  cells,  etc.,  provided  it  is  supplied  with  the 
requisite  intermediary  body ;  or  whether  more  than  one 
complement  is  present  in  the  serum — one  perhaps  capable 
of  producing  haemolysis,  another  of  causing  bacteriolysis. 
The  mode  of  experimenting  is  by  "preparing"  or  "sensi- 
tizing "  (p.  11)  bacteria  and  corpuscles  with  a  certain 
immune  body,  and  then  adding  these  prepared  bacteria  or 
corpuscles  to  a  specimen  of  serum  till  no  more  lysis  takes 
place.  When  the  serum  has  thus  been  saturated  with  one 
kind  of  organism  or  corpuscles  till  it  can  dissolve  no  more, 
a  second  variety  of  prepared  body  (corpuscle  or  bacteria)  is 
added,  and  it  is  seen  whether  destruction  of  any  of  this 
occurs.  Results  appear  to  be  contradictory.  Bordet  and 


PLURALITY  OF    COMPLEMENT  37 

Biichner  hold  to  the  unity  of  the  complement ;  Metch- 
nikoff,  Neisser,  Ehrlich,  and  Morgenroth  support  a  plu- 
rality.1 It  is  quite  possible  that  the  same  answer  to  the 
question  may  not  hold  good  in  all  species  of  animals. 
There  is  considerable  eviden'ce,  however,  pointing  to  the 
fact  that — at  all  events,  in  some  instances — the  complement 
which  causes  haemolysis  may  be  different  from  that 
causing  bacteriolysis  in  the  same  animal.  Neisser 2  has 
shown  that  rabbit's  serum  can  be  deprived  of  its  bacterio- 
lytic  complement  by  addition  of  anthrax  bacilli,  but  that  it 
still  remains  capable  of  haemolysis.  Gengou  and  Tarasse- 
vitch s  have  adduced  experiments  tending  to  show  that 
different  kinds  of  leucocytes  are  the  sources  of  hiemolytic 
and  bacteriolytic  complements  respectively — the  "micro- 
phages "  producing  complement  necessary  for  bacterio- 
lysis, the  "  macrophages  "  that  for  haemolysis. 

Forster  l  finds  that  the  same  complement  in  goat's 
serum  acts  against  the  organisms  both  of  cholera  and  of 
typhoid. 

Dangers  of  excess  of  antibodies.— It  has  been 
suggested5  that  the  presence  of  excess  of  antitoxic  serum 
may  have  an  ill  effect,  since  the  antitoxin  which  is  not 
employed  in  neutralizing  toxin  might  give  rise  to  the 
formation  of  anti-antitoxin,  which  would  prevent  the 
action  of  antitoxin  in  the  future  stages  of  the  disease. 
This  does  not  appear,  however,  to  constitute  a  practical 
danger  in  therapeutics  ;  and  considering  the  entire  ignorance 
which  exists  with  regard  to  the  exact  quantity  of  toxin 
present  in  any  given  case,  we  must  continue  to  be  guided 
by  purely  empirical  rules  for  administration  of  antitoxins. 
A  danger  similar,  to  that  just  mentioned  is  said  to  exist  in 

1  See  Ann.  de  PInst.  Pasteur,    1899,   1900;   Berlin,  kiln.  WocJi., 
1899,  1900,  1901. 

2  Deut.  med,   Woch.,  1900. 

3  Ann.  de  Flnst.  Pasteur,  1900,  1901. 

4  Lancet,  1905,  ii.  1631. 

5  See  Ainloy  Walker,  Ctin.  Joxr».,  June  17,  1903,  p.  144. 


38         SERUMS,    VACCINES,    AND    TOXINS 

the  case  of  antibacterial  serums.  If  an  excess  of  such  a 
serum  be  administered,  there  is  produced  an  excess  of  copula 
in  the  absence  of  sufficient  complement.  When  the  former 
unites  with  the  bacteria,  its  affinity  for  the  complement 
appears  to  be  reduced;  at  all  events,  it  is  not  increased. 
The  free  copula  (the  excess)  then  appears  to  attach  itself 
to  the  available  complement,  and  we  have  bacteria  with 
copula  attached  to  them,  and  complement  molecules  with 
copula  attached  to  them.  This  double  combination  seems 
to  prevent  bacteriolysis,  as  it  would  be  necessary,  in  order 
that  this  should  occur,  for  copula  to  unite  with  copula, 
which  is  not  possible. 

Deficiency  Of  Complement. — So  far  we  have  paid 
more  attention  perhaps  to  the  copula  than  to  the  comple- 
ment in  the  production  of  immunity.  But  susceptibility  to 
disease  may  depend  on  lack  of  sufficient  complement  as  much 
as  on  defect  of  the  intermediary.  Some  individuals  may 
be  naturally  ill  supplied  with  complement.  In  others  pre- 
existing disease  may  exhaust  the  supply.  Thus  it  has  been 
shown  that  in  chronic  maladies  (carcinoma,  Bright's  disease, 
etc.)  the  quantity  of  complement  present  in  the  serum  tends 
to  fall,  and  in  this  way  we  may  explain  the  tendency  to 
terminal  acute  infections  in  these  conditions.  Excessive 
exertion  may  perhaps  cause  destruction  of  complement,  and 
thus  predispose  to  infectious  diseases.  The  use  of  such 
remedies  as  yeast  and  cinnamic  acid  may  lie  in  their  power 
of  supplying  complements,  the  former  perhaps  directly,  the 
latter  by  stimulating  leucocytosis — the  leucocytes  being, 
according  to  some  authors,  the  main  source  of  complement. 

Fixation  or  deviation  of  complement.— As  already 
mentioned  (p.  8),  if  a  hsemolytic  serum  be  heated,  so  as  to 
destroy  the  complement  present  ("inactivated"),  and  be 
then  brought  into  contact  with  appropriate  blood-corpuscles, 
the  copula  present  attaches  itself  to  these  (Fig.  8,  A),  and 
haemolysis  will  result  if  a  supply  of  complement  is  provided 
by  contact  with  fresh  serum.  (It  is  found  that  the  com- 
plement may  in  many  instances  be  provided  by  the  serum 


FIXATION   OF    COMPLEMENT 


39 


of  quite  a  different  species  of  animal  :  thus,  with  a  mixture 
of  heated  hsemolytic  rabbit's  serum  and  corresponding  ox- 
corpuscles,  haemolysis  will  result  on  addition  of  goat's 
serum.)  If,  on  the  other  hand,  the  complement  and  the 
copula  be  left  in  contact  with  one  another  (Fig.*  8,  B),  no 
union  results  :  consequently,  in  such  a  mixture  as  the  latter 
(B)  the  complement  is  still  free,  and  will  bring  about  haemo- 
lysis if  the  second  mixture  is  added  to  the  first  (A),  in  which 
there  is  copula  along  with  corpuscles.  If,  however,  to  the 
second  mixture  (B  —  complement  +  copula)  some  appropriate 


A.  Heated  haeinolytic 
rabbit-serum  and 
ox-  corpuscles 

(Copula  attached 
to  corpuscles) 


B.  Goat -serum  and 
heated  hasmolytic 
rabbit -serum 
(Free  complement 
and  copula) 

Fig.  8  (see  text). 


C.(  B  +  antigen) 
Addition  of  ox- 
corpuscles  to  B 
produces  fixation 
of  complement. 


corpuscles  be  added,  haemolysis  ensues  (Fig.  8,  c) :  the 
complement  is  used  up  in  the  process  and  is  no  longer  free 
to  produce  further  haemolysis  in  mixture  A.  A  means  of 
testing  for  the  presence  of  the  appropriate  corpuscles  is  thus 
provided ;  for  if  a  liquid  containing  appropriate  corpuscles 
is  added  to  mixture  B,  the  complement  in  the  latter  is  fixed 
(attached  by  the  copula  to  the  corpuscles)  and  haemolysis 
occurs ;  whereas  if  the  corpuscles  added  are  inappropriate 
(belonging  to  some  other  species  of  animal  than  that 
used  for  the  original  preparation  of  the  haemolytic  serum, 
and  therefore  unable  to  become  attached  to  the  copula), 
no  fixation  occurs  and  the  complement  remains  free — • 


40         SEEUMS3    VACCINES,    AND    TOXINS 

consequently  no  haemolysis  takes  place.  Not  only  blood- 
corpuscles  but  many  other  albuminous  bodies,  when  injected 
into  animals  of  a  different  species,  produce  corresponding 
antibodies  (copulas).  Each  of  these,  by  union  with  the 
existing  complement,  is  able  to  combine  with  its  appro- 
priate antigen — thus  the  test  may  be  applied  to  detect 
the  presence  of  any  specific  antibody. 

For  example,  if  a  mixture  be  made  of  (a)  syphilitic 
antigen,  represented  by  an  extract  of  syphilitic  fetal  liver, 
(6)  syphilitic  antibody  contained  in  inactivated  serum  from 
a  case  of  syphilis,  and  (c)  complement,  these  three  bodies 
become  linked  together,  and  the  addition  of  the  mixture 
to  sensitized  red  corpuscles  (as,  for  instance,  in  mixture  A, 
Fig.  8)  is  not  followed  by  haemolysis,  as  the  complement 
is  "  fixed  "  to  the  syphilitic  "  antigen-antibody  "  combination, 
and  is  therefore  not  available  to  complete  the  hsemolytic 
system.  In  this  connection  may  be  mentioned  the  reactions 
associated  with  the  names  of  Gengou  (precipitation),  Neisser 
and  Wechsberg  (bacteriolysis),  and  Wassermann  (syphilis). 
See  also  Chapters  IV.  and  XXI. 


CHAPTER  II 
PREPARATION    AND    ADMINISTRATION   OF   SERUMS 

Theory  of  serum  treatment. — As  previously  explained 
(p.  4),  an  antitoxic  serum  is  one  which  has  the  power  of 
neutralizing  the  exotoxin  or  soluble  poison  elaborated  by 
a  particular  micro-organism.  It  can  only  be  relied  upon 
to  combine  with  free  toxin  encountered  in  the  plasma  or 
lymph  of  the  infected  animal  or  patient.  It  has  no 
destructive  effect  on  the  organisms  which  are  causing  the 
disease.  It  may  also  confer  a  transitory  passive  immunity, 
and  so  exert  a  prophylactic  action,  but  this  immunity 
is  rapidly  lost  owing  to  excretion  of  the  antitoxin  or  to 
its  destruction  by  specific  ferments  (p.  21).  On  the  other 
hand,  an  antibacterial  serum  when  fresh  may  contain 
within  it  the  two  bodies,  copula  and  complement,  necessary 
for  effecting  bacteriolysis  ;  later  it  probably  contains  little 
complement  and  needs  to  be  supplemented  by  the  supply  of 
this  body  present  in  the  plasma  of  the  patient.  So  far 
from  being  antitoxic,  such  a  serum  may  theoretically  cause 
liberation  of  an  increased  quantity  of  endotoxin  by  its 
"lytic"  or  solvent  action  on  the  bacteria,  but  it  may 
possibly  in  some  instances  possess  the  power  of  causing 
further  decomposition  of  the  poisonous  protein,  so  that 
ill  effects  are  not  produced.  Certain  serums  which  possess 
apparently  some  bactericidal  power  are  yet  not  bacterio- 
lytic  in  vitro.  Such  have  been  supposed  to  exercise  an 
opsonizing  action,  and  thus  to  increase  phagocytosis. 

Preparation  of  antitoxic  serum. — Some  account  of 

the  preparation  of  individual  serums  will  be  found  under 
their  separate  headings ;  only  a  general  outline  of  the 

41 


42         SERUMS,    VACCINES,    AND    TOXINS 

processes  adopted  will  here  be  given.  It  is  necessary,  first 
of  all,  to  make  sure  that  the  animal  (generally  a  horse) 
selected  to  serve  as  the  factory  for  antiserum  is  itself  free 
from  disease  of  any  kind  which  might  be  transmitted  to 
human  beings.  For  this  purpose  it  is  submitted  to  a  pre- 
liminary test  by  being  injected  with  tuberculin  (see  p.  299) 
to  bring  into  prominence  any  latent  tuberculous  infection, 
and  with  mallein  (see  p.  '204)  to  demonstrate  similarly  any 
unsuspected  glanders  —  the  presence  of  either  of  these 
diseases  obviously  rendering  it  unsuitable  for  the  pro- 
duction of  remedial  antiserum.  Should  the  animal  prove 
sound,  it  is  in  some  cases  first  inoculated  with  a  dose  of 
attenuated  (weakened)  toxin,  prepared  by  heating  the 
virulent  poison  or  by  treating  it  with  some  chemical  agent 
which  reduces  its  strength.  After  this  the  animal  is  inocu- 
lated with  increasing  doses  of  the  virulent  poison  at 
stated  intervals  of  time.  Each  dose  is  generally  sufficient 
to  produce  some  febrile  reaction,  from  which  the  horse 
recovers  in  the  intervals.  The  doses  are  given,  as  a  rule, 
subcutaneously,  but  they  may  finally  be  administered  intra- 
venously when  a  high  degree  of  immunity  has  been  attained. 
Sometimes,  as  a  finishing  touch,  the  bodies  of  the  actual 
dead  organisms  are  injected.  The  horses  used  for  the  pre- 
paration of  serum  generally  flourish  under  the  treatment, 
and  grow  sleek  and  fat.  They  are  liable,  however,  aft  or  a 
time  to  develop  symptoms  of  disease  ;  amyloid  change  may 
occur  in  the  liver  and  spleen,  and  a  fatal  hwmorrhagic 
hepatitis  may  sometimes  ensue.1 

The  toxins  used  for  injection  are  prepared  by  growing 
the  organisms  in  suitable  fluid  media;  the  cultures  are 
then  passed  through  a  Pasteur-Chamberland  or  other  similar 
filter  of  porcelain,  in  order  to  remove  the  bodies  of  the 
bacteria.  It  is  important  that  the  toxins  should  be  as 
potent  as  possible,  and  special  methods  are  adopted  to 
secure  the  highest  possible  degree  of  virulence. 

As  the  site  for  the  injections  administered  to  the  horse 
1  Lewis,  Joto-n.  of  Mrd,  Research.  1906,  xv.  it!). 


ANTIBACTERIAL    SERUM  43 

the  root  of  the  neck  is  generally  selected,  the  hair 
being  first  shaved,  and  the  skin  thoroughly  scrubbed  with 
lysol  or  some  other  antiseptic.  When,  after  a  number 
of  serial  injections,  a  sufficient  degree  of  immunity  has 
been  reached,  the  blood  is  withdrawn  from  the  jugular  vein 
by  means  of  a  simple  incision  through  the  skin,  made 
with  all  antiseptic  precautions,  a  sterile  cannula  being 
thrust  into  the  vein,  and  the  blood  received  into  sterilized 
vessels.  In  these  it  remains  till  coagulation  has  taken 
place,  and  the  free  serum  is  then  decanted  off  and  mixed 
with  a  small  quantity  of  some  antiseptic.  It  is  transferred 
to  bottles  of  convenient  size,  and  is  ready  for  use.  A  large 
quantity  of  blood  can  be  obtained  at  a  single  operation  from 
a  horse  (16  to  20  pints  from  a  good-sized  animal)  without 
ill  effects.  It  is  important  to  wait  for  a  few  days  after 
the  last  injection  of  toxin  before  withdrawing  the  blood, 
as  otherwise  the  serum  may  contain  poisonous  material. 

Preparation  of  antibacterial  serum.— Antibacterial 
serums  are  produced  by  a  method  very  similar  to  that  used 
for  preparing  antitoxic  serums,  but  the  actual  bodies  of  the 
bacteria  are  injected  instead  of  the  filtraf^  from  a  fluid 
medium.  Sometimes  the  dead  bodies  of  the  organisms  are 
first  used,  or  an  attenuated  culture,  the  virulent  bacteria 
being  withheld  till  some  degree  of  tolerance  is  established. 
A  dose  of  corresponding  antiserum  may  be  used  to  mitigate 
the  effects  of  the  first  dose,  if  it  be  available.  In  the  case 
of  antibacterial  serums  it  is  most  important  that  the  pre- 
paration used  for  treatment  of  disease  should  be  freshly 
made,  since  it  has  been  shown  that  the  value  of  such 
serums  rapidly  falls. 

Two  special,  factors  enter  into  the  question  of  the 
manufacture  of  antibacterial  serums  which  do  not  apply  to 
antitoxic  preparations.  In  the  first  place  it  is  found  that 
many  species  of  bacteria  comprise  different  strains  or  varieties 
which  react  differently  towards. protective  serums.  Thus,  a 
serum  may  be  prepared  which  will  be  fatal  to  a  certain 
strain  of  streptococci — the  variety  used  for  its  preparation 


44         SERUMS,    VACCINES,    AND    TOXINS 

— but  which  will  have  no  similar  effect  on  another  race  of 
the  same  organisms,  derived  perhaps  from  a  different 
patient  or  from  a  slightly  different  form  of  pyogenic  disease. 
Now,  in  any  individual  case  of  illness  we  cannot  tell  what 
strain  of  bacteria  may  be  present,  and  therefore  in  preparing 
a  serum  for  practical  therapeutics  it  is  advisable  to  use 
several  strains  for  the  purpose  of  immunizing  the  animal,  in 
order  that  the  chances  of  combating  the  causal  organism 
in  any  human  patient  may  be  increased.  A  serum  thus 
prepared  with  several  strains  of  an  organism  is  said  to  be 
"polyvalent." 

Again,  as  has  already  been  pointed  out,  it  does  not 
follow  that  the  complement  existing  in  the  body  of  one 
animal  will  be  capable  of  uniting  with  the  copula  supplied 
by  another  animal,  so  as  to  destroy  a  given  bacterium.  An 
antibacterial  serum  originally,  no  doubt,  possesses  in  itself 
both  complement  and  intermediary  body.  But  the  former  is 
an  unstable  substance  :  it  rapidly  vanishes  from  the  serum 
when  kept,1  and  it  is  not  improbable  that  it  is  destroyed 
when  the  serum  is  injected  into  another  kind  of  animal. 
Hence  the  copula  contained  in  the  immune  serum  may  have 
to  depend  on  a  complement  found  in  the  animal  or  man 
to  which  the  serum  is  administered,  if  it  is  to  have  a 
bactericidal  effect.  If  the  two  bodies  do  not  fit  one  another, 
no  curative  result  will  ensue.  It  has  been  recommended, 
therefore,  that  serums  for  human  use  should  be  prepared 
from  some  animal  nearly  allied  to  man,  such  as  the  ape. 
Such  a  serum  is  said  to  be  "  homologous." 

In  the  case  of  many  antibacterial  serums — for  example, 
those  prepared  against  streptococci  and  pneumococci — the 
presence  of  leucocytes  seems  necessary  to  the  action  of  the 
serum.  Possibly  it  is  an  opsonizing  influence  that  is 
exerted,  rather  than  a  true  bacteriolysis. 

Testing"  serum.— Before  a  specimen  of  serum  is  issued 
for  use  it  ought  to  be  tested,  to  ensure  that  it  is  free  from 
contamination.  It  must  not  contain  living  bacteria  or 
1  See  Ainley  Walker,  Lancet,  1901,  i.  18. 


STANDARDIZATION    OF    SERUM  45 

toxins.  In  order  to  test  it,  portions  of  it  must  be  mixed 
with  culture-medium  and  incubated — some  aerobically, 
some  anaerobically — to  see  if  any  bacteria  develop.  Some 
of  it  must  also  be  injected  into  an  animal  to  make  sure 
that  it  is  not  toxic.  Cases  have  occurred  in  which  death 
has  been  caused  by  the  use  of  a  serum  containing  the 
toxins  of  tetanus. 

Standardization  of  serums. — Since  it  has  hitherto 
been  found  impossible  to  isolate  the  actual  toxins  of 
bacteria,  so  that  no  process  of  weighing  or  measuring  can 
be  applied  to  them,  it  is  necessary  to  devise  some  other  way 
of  calculating  their  strength.  A  physiological  test  of  some 
sort  is  the  only  available  nieans  of  measuring  their  effects. 
For  this  purpose  it  is  necessary  to  find  some  animal  which 
reacts  in  a  constant  manner  to  the  poison,  dying  regularly 
witliin  a  certain  time  as  the  result  of  a  given  dose  of 
toxin.  In  the  case  of  the  diphtherial  toxins  it  is  found 
that  guineapigs  are  suitable  test  animals.  It  is  possible  to 
ascertain  accurately  the  quantity  of  a  particular  specimen 
of  poison  which  will  invariably  cause  the  death  of  a  guinea- 
pig  of  a  certain  weight  (250  grammes)  on  the  fourth  day. 
This  is  taken  as  the  standard  dose  of  poison,  or  "  minimal 
lethal  dose."  It  is  then  necessary  to  find  what  amount  of 
antitoxin  is  required  to  neutralize  this  dose  exactly,  and  we 
find  that  equal  quantities  of  a  given  antitoxin  will  perform 
this  duty.  A  standard  is  thus  set  up.  What  is  known  as 
a  "  unit "  of  antitoxin  is  that  quantity  of  antitoxic  serum 
which  will  exactly  neutralize  100  minimum  lethal  doses  as 
above  defined,  i.e.  an  amount  of  which  a  one-hundredth 
part  will  prevent  the  appearance  of  any  morbid  symptoms 
in  a  guiueapig,(if  injected  along  with  the  minimal  dose  of 
toxin  which  would  otherwise  kill  it  within  four  days. 

In  the  case  of  an  antibacterial  serum  the  matter  is 
rather  more  complicated.  We  may  take  as  an  example  a 
serum  which  destroys  cholera  vibrios.  Such  serum,  if  in- 
jected into  the  peritoneal  cavity  of  a  normal  animal  along 
with  a  loopful  of  virulent  cholera  organisms,  will  rapidly 


46         SERUMS,    VACCINES,    AND    TOXINS 

cause  their  disintegration ;  but,  on  the  other  hand,  the 
bacteria,  if  injected  into  the  abdomen  of  an  animal  (not 
immune)  without  .any  protective  serum,  rapidly  multiply 
and  kill  the  animal.  In  testing  the  strength  of  a  serum 
different  portions  are  diluted  for  the  sake  of  accuracy, 
to  (say)  1  :  100  and  1  :  1,000.  Two  guineapigs  are  taken, 
one  of  which  receives  1  c.c.  of  the  first  dilution  along 
with  a  loopful  of  a  virulent  culture  of  cholera  vibrios, 
while  the  other  receives  the  same  quantity  of  the  second 
dilution  with  a  similar  loopful  of  ,the  bacteria.  Within 
forty  minutes  search  is  made  in  the  peritoneal  cavities  of  the 
animals  to  see  whether  the  vibrios  therein  are  flourishing  or 
are  disintegrating.  If  the  smaller  dose  of  serum  has  failed 
to  kill  them,  while  the  larger  one  has  done  so,  further  experi- 
ments are  made  to  determine  the  exact  quantity  of  serum 
which  just  suffices  for  the  purpose;  if  the  lower  dose  has 
proved  sufficient,  then  still  smaller  quantities  are  tried,  and 
that  dilution  of  the  serum  which  is  finally  determined  (e.g. 
1  :  500)  is  used  to  indicate  the  valency  of  the  antiserum. 
Owing,  however,  to  the  difficulty  of  estimating  the  exact 
number  and  the  virulence  of  the  bacteria  introduced, 
antibacterial  serums  cannot  be  standardized  with  the  same 
precision  as  antitoxic  serums,  so  their  value  is  very  rarely 
referred  to  in  terms  of  "  units." 

ADMINISTRATION    OF    SERUM 

Early  administration. — The  symptoms  of  an  in- 
fective disease  are  due  to  the  effects  produced  on  the 
cells  and  tissues  of  the  body  by  the  toxins  of  its  specific 
micro-organism,  and  consist  in  the  resulting  perversions 
of  function ;  while  the  action  of  an  antitoxic  serum  is  to 
neutralize  the  poison  circulating  free  in  the  blood  and 
lymph,  although  it  does  not  prevent  the  growth  of  the 
bacteria  or  exercise  any  restraining  effect  on  them. 
Now,  as  the  bacteria  pour  out  a  ^constant  stream  of 
toxin,  and  this  is  continually  entering  into  combination 
with  the  side-chains  (receptoi-s)  of  the  cells,  it  is  most 


ADMINISTRATION   OF    SERUM  47 

important  to  introduce  the  antidote  as  soon  as  possible, 
before  any  great  amount  of  mischief  is  done.  If  the  disease 
has  too  long  a  start,  the  antitoxin  may  come  too  late  to  be 
of  any  service.  The  great  principle,  therefore,  in  giving 
antitoxin  of  any  kind  is  to  give  it  at  the  beginning  of  the 
disease,  at  the  earliest  possible  moment.  In  the  case  of 
diphtheria,  statistics  show  conclusively  that  the  power  of 
the  remedy  over  the  disease  varies  directly  with  the 
promptitude  of  its  administration,  while  in  the  case  of 
tetanus  there  seems  reason  to  doubt  whether  it  is  not 
already  too  late,  in  man  at  all  events,  to  use  the  antitoxin 
when  the  malady  has  declared  itself.  (See  pp.  114  and  146.) 
Large  dose. — A  second  principle  is  to  administer  a 
large  initial  dose,  since  we  do  not  in  any  case  know  the 
amount  of  toxin  which  has  to  be  counteracted,  and  the 
supply  of  the  latter  is  constantly  increasing,  whereas  the 
remedy  is  given  all  at  once  in  a  single  dose,  and  is  not  in 
any  case  repeated  for  some  hours  afterwards.  There  is  also 
the  possibility  that  the  presence  of  a  very  large  quantity  of 
the  antitoxin  may  tend  to  withdraw  from  the  cells  any 
poison  which  has  already  united  with  them.  Similarly, 
we  ought  not  to  hesitate  to  repeat  the  dose,  if  it  seem  in 
the  least  necessary.  It  is  better  to  err  on  the  side  of 
giving  too  much  than  too  little.  The  danger  of  producing 
anti-antitoxin  or  anticomplement,  previously  alluded  to 
(p.  37),  does  not  seem  to  exist  in  practical  therapeutics, 
though  it  might  suggest  the  advisability  of  giving  quite 
small  doses  of  serum  for  prophylactic  purposes.  If,  how- 
ever, the  previous  administration  of  serum  to  a  patient 
suggest  the  danger  of  anaphylaxis,  the  following  method, 
devised  by  Besredka,1  may  be  put  into  practice.  Small 
quantities  (1,  3,'  or  10  c.c.)  of  diluted  serum  (1  :  10)  are 
injected  intravenously  at  short  intervals  of  a  few  minutes. 
After  another  similar  short  interval  a  moderate  dose  of  the 
diluted  serum  (25  c.c.)  is  injected  ;  after  which,  allowing  an 
interval  of  twenty  minutes,  a  full  dose  of  undiluted  serum 
1  Internal  Congress  of  Med. ,  1913 


48         SERUMS,    VACCINES,    AND    TOXINS 

can  be  administered  by  any  route  desired,  without  fear  of 
anaphylactic  symptoms  ensuing. 

Fresh  serum. — Thirdly,  it  is  important  that  the  serum 
which  is  used  should  be  as  fresh  as  possible,  as  there  is 
evidence  that  the  remedy  tends  to  deteriorate  in  course 
of  time.  How  long  the  different  serums  may  retain  their 
specific  powers  is  not  yet  definitely  settled,  and  in  the 
case  of  diphtherial  antitoxin  it  seems  probable  that  it  may 
remain  effective  for  at  least  two  years.  But  there  has  been 
shown  to  be  a  slow  process  of  deterioration  at  work  in  all 
cases,  so  that,  in  order  to  be  on  the  safe  side,  it  is  well  to 
use  only  quite  fresh  serum.  If  this  is  not  to  be  obtained, 
or  only  after  some  delay,  an  older  brand  should  be  used 
rather  than  none  at  all,  in  preference  to  delaying  unduly 
the  administration  of  the  initial  dose.  The  same  rule  also 
applies  to  vaccines,  which  should  be  used  fresh. 

The  syringe. — The  syringe  for  hypodermic  injection 
of  serum  should  be  of  a  capacity  of  not  less  than  10  c.c.,  as  this 
is  the  dose  of  serum  usually  given,  and  it  is  inconvenient  to 
refill  the  syringe  during  the  administration  of  the  dose.  On 
the  other  hand,  syringes  of  20  c.c.  capacity  and  upwards  are 
heavy  and  clumsy  to  handle.  It  should  preferably  have  a 
glass  piston  (Fig.  9),  as  this  can  be  more  readily  sterilized 
than  those  provided  with  an  ordinary  leather  washer.  The 
latter  may,  however,  be  made  of  asbestos  or  of  indiarubber. 
The  needle  should  be  longer  than  that  of  a  common  hypo- 
dermic syringe;  2-2^  in.  is  an  adequate  length.  The 
bore  of  the  needle  need  not  be  large,  as  the  serum  is 
perfectly  fluid,  and  will  pass  readily  through  any  hollow 
needle.  It  is  unnecessary  cruelty  to  employ  the  large- 
bored  instruments  often  supplied,  as  they  cause  considerably 
more  pain,  and  it  is  an  advantage  rather  than  otherwise  to 
give  the  injection  slowly.  The  serum  at  first  causes  a  slight 
swelling  at  the  point  where  it  is  injected,  but  this  soon 
subsides.  Its  diffusion  may  be  aided  by  a  little  massage  of 
the  part,  but  this  is  quite  needless  in  the  majority  of 
instances.  If  a  second  injection  is  required,  it  may  be 


ADMINISTRATION    OF    SERUM  49 

given  at  the  point  corresponding  with  the  first,  but  on  the 
opposite  side  of  the  body.  If  a  series  of  doses  is  necessary, 
rows  of  punctures  may  be  made  in  lines  up  the  two  sides  of 
the  abdomen. 

In  young  infants  the  small  size  of  all  the  parts  must  be 
borne  in  mind,  so  that  the  needle  may  not  be  inserted 
unduly  far.  Cases  are  recorded  in  which  the  pleura  has 
been  punctured  in  the  process  of  injection  in  the  flanks,  and 
gangrene  of  the  lung  has  ensued  with  fatal  result.1  With 
ordinary  care  no  fear  of  injury  to  the  youngest  baby  need 
be  entertained.  In  the  case  of  restless  patients  or  young 
children  it  may  be  advisable  to  interpose  a  rubber  coupling 


Fig.  9.— All-glass  serum  syringe;   readily  sterilized  by  boiling, 
after  separation  of  the  component  parts. 

between  the  needle  and  the  barrel  of  the  syringe  in  order 
to  lessen  the  risk  of  breaking  the  former  in  the  skin- 
puncture. 

The  syringe  and  needle  must  be  carefully  and  thoroughly 
boiled  3  just  before  use  in  every  case ;  and  should  be  allowed 
to  cool  somewhat  before  the  serum  is  drawn  into  them  for 
use,  to  ensure  that  the  temperature  of  the  instrument  is 
not  such  as  to  cause  any  coagulation  of  the  albuminous 
fluid,  whereby  the  needle  might  be  blocked.  After  use 
the  syringe  and  needle  should  be  washed  through,  first  with 
cold  water  and  then  with  some  volatile  antiseptic,  such  as 

1  R.  G.  H.  Tate,  Dublin  Journ.ofMed.  Science,  April,  1900,  p.  271. 

2  In  the  all-glass  syringe  the  parts  should  be  separated  before 
boiling,  to  obviate  danger  of  cracking. 

E 


50         SERUMS,    VACCINES,    AND    TOXINS 

ether  or  alcohol,  and  dried  before  being  returned  to  the 
case. 

Local  USe  Of  serums.  —  In  some  diseases  which 
are  characterized  by  distinct  local  lesions  it  has  been  advised 
to  inject  the  serum  in  the  neighbourhood  of  these,  in  order 
to  procure  a  local  effect.  An  antibacterial  serum  has  been 
used  in  the  form  of  lozenges  in  cases  of  diphtheria,  in  ad- 
dition to  the  use  of  antitoxin  subcutaneously.  Tetanus 
antitoxin  has  been  used  to  saturate  the  dressings  of  the 
infected  wound,  and  the  serum,  dried,  powdered,  and  mixed 
with  chloretone  or  some  inert  powder,  may  be  used  to  dust 
on  the  lacerated  tissues  at  the  seat  of  infection.  In  ery- 
sipelas good  results  have  been  obtained  by  injections  of 
antistreptococcic  serum  into  the  periphery  of  the  inflamed 
area ;  and  in  plague  it  has  been  recommended  to  make  the 
injection  into  some  part  of  the  skin  which  is  drained  by 
the  lymphatics  leading  to  the  bubo. 

Subcutaneous  injection.  —  Antitoxic  serum  is  in 
general  administered  subcutaneously.  It  is  immaterial 
what  spot  is  selected  for  the  injection ;  the  sides  of  the 
abdomen  are  the  favourite  localities,  as  a  rule,  especially 
the  skin  near  the  groin.  The  back,  between  the  shoulders, 
is  equally  convenient,  but  in  the  (unlikely)  event  of  an 
abscess  forming  at  the  point  of  injection,  as  the  result  of 
some  failure  in  antisepsis,  the  lesion  would  add  more  to  the 
discomfort  of  the  patient  in  this  situation  than  if  it  were 
on  the  front  of  the  body,  where  it  would  not  interfere  with 
the  ordinary  dorsal  position  of  rest.  The  skin  should  be 
first  washed  with  ether-soap  and  water,  and  then  with 
some  antiseptic,  such  as  1  :  20  carbolic-acid  lotion,  or  better 
still  with  ordinary  ether,  which  is  then  allowed  to 
evaporate ;  or  the  skin  may  be  painted  with  a  solution  of 
iodine  in  chloroform  or  alcohol  (3  per  cent.).  The  needle  is 
passed  quickly  through  the  skin  into  the  subcutaneous 
tissue,  and  the  fluid  is  injected  fairly  slowly.  The  puncture 
is  then  sealed  with  a  "  scab  "  of  collodion. 

Oral  and  rectal  administration.— Administration 


ADMINISTRATION   OF    SERUM  51 

of  antitoxin  by  the  mouth  is  of  very  doubtful  efficacy 
(p.  32).  If  it  is  desired  to  give  serum  by  this  route,  it- 
may  be  mixed  with  4  or  5  oz.  of  warm,  not  hot,  soup  01 
broth  (100°  F.),  and  thus  effectually  disguised.  Rectal 
injection  is  advised  by  Marmorek  in  the  case  of  his  anti- 
tubercular  serum,  and  has  been  employed  by  some  phy- 
sicians in  the  case  of  diphtherial  antitoxin  (see  pp.  340  and 
117).  For  this  purpose  the  serum  may  be  diluted  with 
normal  saline  solution  to  a  convenient  bulk  (say  2  oz.), 
and  given  by  means  of  a  bulb  syringe,  like  a  nutrient 
enema.  It  should  be  given  at  body  temperature  (98°  F.) 
to  facilitate  its  retention  and  absorption. 

Intravenous  injection. — In  severe  cases  it  has  been 
recommended  to  give  the  remedy  intravenously,  in  order 
that  it  may  be  more  quickly  absorbed  and  so  manifest  its 
effects  more  speedily. 

For  the  purpose  of  intravenous  injections,  in  the  case 
of  a  child,  some  recommend  a  general  anesthetic,  and  for 
an  adult  cocaine-anaesthesia,  since  some  have,  on  occasion, 
found  it  necessary  to  cut  down  upon  and  dissect  out  the 
vein.  We,  however,  are  of  opinion  that  neither  local  nor 
general  anaesthesia  is  necessary. 

The  vein  usually  chosen  is  either  the  median  basilic  or 
median  cephalic  at  the  bend  of  the  elbow  ;  sometimes  one 
is  driven  by  circumstances  to  select  a  superficial  vein  of 
the  forearm  or  hand,  or  else  of  the  leg.  The  preparation 
of  the  patient  is  generally  a  simple  matter,  especially  when 
one  is  able  to  utilize  a  vein  at  the  bend  of  the  elbow,  for 
in  this  situation  the  skin  is  delicate,  hairless,  and  easily 
cleansed.  The  patient  should  be  lying  in  bed  ;  and  the 
arm,  bared  to  the  shoulder,  should  rest  on  a  clean  towel  on 
the  bed  by  the  patient's  side,  or,  better  still,  be  drawn  out 
at  right  angles  to  the  body.  The  skin  must  be  thoroughly 
washed  with  soap  and  water ;  scrubbed  with  ether ;  more 
ether  poured  on  and  allowed  to  evaporate  ;  and  finally  the 
site  for  operation  covered  with  a  piece  of  lint  saturated 
with  ether.  If  iodine  solution  is  xised  it  should  be  washed 

Tl£0 


52         SERUMS,    VACCINES,    AND    TOXINS 

ott'  as  thoroughly  us  possible  with  ether,  otherwise  the 
position  and  course  of  the  vein  may  be  obscured  by  the 
brown  discoloration  of  the  overlying  skin.  If  the  vein 
chosen  is  covered  by  hairy  skin,  the  part  must  be  washed 
up  with  ether-soap  and  carefully  shaved,  the  skin  scrubbed 
up  with  lysol,  and  then,  the  lysol  having  been  thoroughly 
washed  off  with  large  volumes  of  ether,  finally  covered  with 
a  pad  saturated  with  ether. 

The  vein  should  be  rendered  prominent  by  compressing 
it  above  the  bend  of  the  elbow  (this  may  be  done  by 
the  thumb  of  an  assistant),  and  the  needle  introduced 
through  the  skin  into  the  subcutaneous  tissue  at  a  slight 
angle  with  the  plane  of  the  vessel.  Then  the  direction  of 
the  point  is  slightly  altered,  and  it  is  thrust  through  the 
wall  of  the  distended  vein.  As  soon  as  blood  appears 
in  the  barrel  of  the  syringe,  the  assistant  releases  the 
pressure  on  the  vein ;  then  the  piston  should  be  slowly  and 
steadily  pushed  down,  and  the  dose  of  serum  injected  into 
the  vein.  As  the  opening  into  the  vein  is  small,  pressure 
alone  suffices  to  stop  haemorrhage. 

The  serum  should  be  warmed  to  the  temperature  of  the 
body  before  it  is  used  intravenously ;  and  if  it  exhibit  any 
undue  opacity  or  deposit,  it  should  be  strained  through 
sterilized  muslin  before  it  is  drawn  into  the  syringe  for 
injection. 

In  order  to  avoid  any  risk  of  injection  of  air  into  the 
circulation,  it  is  necessary  to  see  that  the  needle  is  full  to  the 
end  with  the  serum  before  it  is  passed  into  the  vein.  There  is 
in  reality  no  danger  to  be  apprehended  if  only  a  bubble  or 
two  of  air  enter  a  vein ;  and  in  vessels  at  a  distance  from 
the  heart  there  is  not  a  sufficient  negative  pressure  to  suck 
air  in,  apart  from  any  injected.  Still,  care  should  be  taken 
in  this  respect,  and  a  finger  may  be  placed  over  the  vein 
on  the  central  (cardiac)  side  of  the  point  punctured,  to 
prevent  any  possibility  of  mishap. 

Intracerebral  injections.  —  Some  recommend  the 
intracerebral  route  for  the  injection  of  antitetanus  or  anti- 


ADMINISTRATION   OF    SEEUM  53 

meiiingococcic  serum.  In  our  opinion,  and  in  view  of  the 
possible  results  of  injury  to  the  cerebral  tissues,  this 
method  should  be  employed  only  as  a  last  resource. 

For  the  purpose  of  intracerebral  injection,  it  is  advisable 
to  prepare  a  specially  strong  serum  l  by  dissolving  the  solid 
(dried)  substance  in  half  the  usual  quantity  of  distilled 
water,  or  by  evaporating  the  liquid  serum  to  half  its  bulk 
at  a  low  temperature  in  vacuo. 

The  procedure  to  be  adopted  is  as  follows :  A  line  is 
drawn  from  one  auditory  meatus  to  the  other,  across  the 
vertex  of  the  skull.  From  the  point  at  which  this  meets 
the  midline  a  second  line  is  drawn  to  the  outer  angle  of  the 
orbit.  The  middle  point  of  this  last  line  gives  the  site  for 
the  injection  (Roux's  point).  An  incision  is  made  in  the 
scalp,  and  a  small  trephine  is  employed  to  remove  a  piece 
of  the  skull.  Abbe  2  says  that  the  operation  can  be  done 
satisfactorily  under  cocaine-anaesthesia.  There  does  not 
seem,  however,  to  be  any  advantage  in  this  over  chloroform, 
as  the  latter  will  control  any  spasm  which  may  occur  during 
the  operation,  while  cocaine  will  not.  An  opening  is  made 
in  the  dura  mater,  and  a  blunt  needle  is  thrust  into  the 
cerebral  substance.  The  serum  must  be  very  slowly  forced 
into  the  brain,  5  c.c.  being  enough  to  use  on  each  side.  It 
would  seem  better  to  endeavour  to  inject  the  antitoxin 
into  the  actual  cerebral  substance  rather  than  into  the  lateral 
ventricle,  as  the  latter  method  is  practically  equivalent  to 
subdural  injection,  which  can  be  more  easily  carried  out,  if 
it  is  desired,  externally  to  the  brain. 

An  actual  trephine-opening  in  the  skull  is  not  necessary 
for  the  intracerebral  injection,  which  can  be  given  through 
a  simple  hole  bored  with  a  drill.  The  large  cerebral  sinuses 
must,  of  course,  be  avoided  in  these  procedures,  and  a 
blunt  needle  is  preferable,  in  order  to  avoid  wounding  the 
smaller  vessels  in  the  substance  of  the  cerebrum. 

A  procedure   similar   to   the    above   may  be   adopted 

1  Church,  New  York  Med.  Journ,  Doc.  17,  1398. 
-  Op.  cit. 


54        SERUMS,    VACCINES,    AND    TOXINS 

for  subdural  injection,  if  it  be  decided  to  give  this  intra- 
cranially,  but  the  method  by  spinal  puncture  is  in  all 
probability  as  effective. 

Intrathecal  injections.— The  introduction  of  the 
antiserum  into  the  spinal  canal  after  lumbar  puncture  is 
essential  in  the  treatment  of  tetanus  and  meningitis.  In 
carrying  out  this  method  the  patient  should  be  arranged  in 
bed  in  the  semiprone  position,  on  whichever  side  is  more 
convenient  to  the  operator,  the  head  being  slightly  raised 
on  a  pillow.  It  is  advisable  to  bend  the  knees  and  flex  the 
thighs  on  the  abdomen,  so  that  the  vertebral  column  is  well 
arched,  and  to  hold  the  patient  firmly  in  this  position. 
The  site  of  operation  for  lumbar  puncture  is  a  10-cm. 
(4-in.)  circle  of  the  skin  of  the  back,  having  its  centre  over 
the  spinous  process  of  the  fourth  lumbar  vertebra.  This 
central  point  can  be  identified  by  the  simple  method  of 
counting  the  vertebrae  downwards,  or  by  the  help  of  a  line 
joining  the  highest  points  of  the  iliac  crests,  which  thus 
crosses  the  fourth  lumbar  vertebra.  Adjust  either  the  bed 
or  the  light  so  that  the  field  of  operation  is  well  lighted ; 
then  prepare  the  skin,  over  the  area  already  indicated,  in  the 
same  way  as  at  the  bend  of  the  elbow  for  the  intravenous 
injection.  .  The  all-glass  syringe,  sterilized  as  previously 
described,  must  be  provided  with  a  somewhat  longer  needle 
(from  6-7  cm.  long  for  children,  to  9  cm.  long  for  obese 
adults)  than  that  used  for  intravenous  injection.  The 
needle  is  introduced  vertically  to  the  surface  of  the  skin, 
into  the  interspace  between  the  third  and  fourth  lumbar 
vertebrae,  and  pushed  on  between  the  lamina?  into  the 
spinal  canal ;  and  fluid  is  carefully  withdrawn,  so  long 
as  an  abnormal  pressure  is  noted,  or,  if  no  obvious 
pressure  exists,  until  a  rather  larger  volume  has  been 
abstracted  than  it  is  intended  to  replace  by  serum.  The 
syringe  is  then  detached  from  the  needle,  the  latter 
being  left  in  situ,  a  second  syringe  containing  the  anti- 
serum,  previously  warmed  to  body  temperature,  being  ad- 
justed in  the  place  of  the  first  syringe,  and  the  injection 


ADMINISTRATION   OF    SERUM  55 

made  slowly  into  the  spinal  canal.  In  withdrawing  the 
cerebro-spinal  fluid,  and  also  in  injecting  the  serum,  a  careful 
watch  should  be  maintained  over  both  the  "pulse  and  respi- 
ration ;  indeed,  Sophian1  has  suggested  that  in  the  course 
of  intrathecal  injections  of  serum,  especially  where  it  is 
desired  to  introduce  a  large  volume  of  fluid,  the  blood- 
pressure  should  be  recorded  throughout  the  operation,  and 
the  injection  stopped  when  the  pressure  falls  to  any  appre- 
ciable extent  (e.g.  a  drop  of  20  to  30  mm.  Hg).  When 
the  injection  is  completed,  the  needle  should  be  with- 
drawn from  the  body,  and  the  site  of  puncture  sealed 
with  a  dressing  of  gauze  and  collodion  or  with  a  small 
piece  of  adhesive  strapping. 

Intramuscular  injection. — It  was  shown  by  Meltzer 

and  Auer 2  that  solutions  of  salts  were  more  rapidly 
absorbed  into  the  system  when  injected  into  the  muscles 
than  when  given  hypodermically  ;  and  Morgenroth  3  found 
that  the  same  was  true  of  colloid  solutions,  such  as  serum. 
Practical  use  of  this  mode  of  administration  was  first  made 
by  Neisser  and  his  assistants  at  Stettin,  and  since  then 
many  physicians  have  preferi-ed  this  route.  Rolleston  and 
MacLeod  l  in  this  country  speak  highly  of  it,  holding  that 
this  method  should  supersede  all  others,  since  not  only  is  it 
simple  to  carry  out,  but  it  is  less  painful  and  less  liable  to 
cause  abscesses  than  the  subcutaneous  method,  while  it  is 
more  rapid  in  its  effects,  and  has  the  advantage  over  the 
intravenous  route  that  the  antitoxin  is  less  rapidly  excreted 
(or  destroyed).  The  site  of  injection  may  be  either  the 
gluteal  muscles  or  the  vastus  externus  of  the  thigh. 

OCCASIONAL  ILL  EFFECTS  OF  SERUM 

Effects   on   man    of  the    serum   of  the    lower 
animals. — It   is   probable    that   the   blood-serum   is   not 

1  Journ.  Amer.  Ned.  Assoc.,  1912,  p.  843. 

2  Journ.  Exp.  Med.,  1905,  vii.  59. 

3  Berl.  Urn.  Woch.,  1907,  xliv.  1349. 

4  Brit.  Journ.  Child.  I)is..  1914.  xi.  298. 


5(5         SERUMS,    VACCINES,    AND    TOXINS 

identical  in  composition  in  any  two  species  of  animals. 
We  have  already  alluded  (p.  11)  to  the  poisonous  effects 
produced  in  mammalian  animals  by  injection  of  eel's 
serum,  by  which  an  actual  haemolysis  is  brought  about. 
Other  serums  possess  varying  degrees  of  toxicity.  Anti- 
toxic and  immune  serums  are  necessarily  prepared  from 
the  blood  of  the  lower  animals,  and  the  horse  is 
usually  chosen  for  the  purpose  on  account  of  its  size, 
which  enables  a  considerable  quantity  of  blood  to  be 
drawn  at  a  time,  as  well  as  owing  to  the  comparatively 
innocuous  nature  of  the  serum  of  this  animal  in  its  action 
on  man.  The  injection  of  normal  horse's  serum  into  man 
may,  however,  be  followed  by  certain  results  of  an  un- 
pleasant, and  at  times  even  dangerous,  character.  It  is 
found  that  the  serum  of  some  horses  induces  such  results 
in  larger  measure  than  that  of  others.  The  fact  that  a 
horse  has  been  immunized  to  a  certain  toxin  or  organism 
does  not  seem  to  have  anything  to  do  with  the  production 
of  the  symptoms  referred  to ;  the  peculiarity  resides  in  the 
serum  of  the  animal,  and  is  uninfluenced  by  the  matters 
used  for  inoculation.  It  is  also  possible  that  an  idiosyncrasy 
on  the  part  of  the  patient  injected  may  be  the  origin  of 
some  of  the  ill  effects  noticed.  In  such  cases  the  hypo- 
thesis that  the  patient  has  become  sensitized  by  the 
previous  ingestion  of  horseflesh  (which  on  the  Continent 
of  Europe  is  a  fairly  common  article  of  diet)  has  been 
advanced.  More  frequently  seen,  and  more  severe,  are 
the  disturbances  which  may  follow  a  second  or  subsequent 
injection  of  serum,  owing  to  the  supervention  of  a  state  of 
anaphylaxis  or  increased  sensibility  to  the  protein  of  horse- 
serum.  To  meet  this  danger  both  the  ox  and  the  ass  have 
been  utilized  for  the  production  of  antidiphtherial  serum 
to  be  used  for  patients  possibly  already  sensitized  to  horse- 
serum  ;  but  it  would  appear  simpler  to  adopt  Besredka's 
method  of  anti-anaphylactic  vaccination  (p.  47)  in  such 
cases.  Anti-anthrax  serum  is  derived  from  the  mule,  and 
anti-pneumococcic  serum  from  the  goat. 


ILL    EFFECTS   OF    SERUM  57 

Nature  Of  symptoms. — As  the  most  frequently  used 
serum  is  the  diphtherial  antitoxin,  it  is  chiefly  in  the  case 
of  this  remedy  that  ill  effects  have  been  observed.  They 
consist  in  cutaneous  eruptions  of  various  kinds  (pp.  128-30), 
pains  with  some  swelling  and  tenderness  in  the  joints,  and 
occasionally  rise  of  temperature  and  feeling  of  illness.  A 
good  deal  of  itching  is  frequently  met  with  at  the  site  of 
injection.  The  rashes  appear,  for  the  most  part,  some  time 
after  the  administration  of  the  serum  (second  week),  and 
are  of  the  type  known  as  erythema  multiforme,  i.e.  they  pre- 
sent many  different  appearances — erythematous,  urticaria!, 
scarlatiniform,  morbilliform,  etc. — but  all  are  essentially 
conditions  of  hypersemia  and  escape  of  serum  into  the  tissue- 
spaces  in  varying  proportions.  Sometimes  the  hyperzemia 
predominates  (erythema,  etc.) ;  sometimes  the  escape  of 
serum  (urticaria).  In  a  very  few  instances  more  serious 
effects  have  ensued.  Thus  Rauschenbusch1  records  the 
case  of  a  child  who  received  a  prophylactic  injection  of 
antitoxin,  and  who  was  seized  with  "giddiness,  faint- 
ness,  vomiting,  and  cutaneous  irritation,  with  urticarial 
wheals,  within  a  few  minutes  of  the  injection."  She 
remained  ill  for  some  hours,  but  was  nearly  well  on  the 
following  day.  Actual  death  may  occur.  A  few  instances 
have  been  recorded  after  the  use  of  diphtherial  anti- 
toxin (p.  126),  and  the  present  writers  have  seen  a  case  in 
which  an  injection  of  antistreptococcic  serum  in  a  patient 
suffering  from  pernicious  anaemia  was  quickly  followed 
by  coma  and  death.  When,  however,  we  consider  the 
enormous  number  of  injections  of  serum  of  all  kinds  that 
are  given,  the  number  of  fatal  cases  reported  2 — and  it  is 
probable  that  scarcely  a  single  one  of  such  fatalities  escapes 
record,  from  its  very  rarity — becomes  almost  infinitesimal. 

1  Quoted  by  Durham,  art.  "  Antitoxins,"  in  "  Quain's  Dictionary 
of  Medicine,"  1902. 

2  Some    of    these    fatalities    are    probably    attributable   to   the 
existence  in  the  child  of  the  "status  lymphaticus,"  in  which  sudden 
death  may  follow  the  most  trivial  injuries -or  operations. 


58         SERUMS,    VACCINES,    AND    TOXINS 

The  risk  is  much  less  than  that  of  the  smallest  surgical 
operation,  and  can  be  entirely  neglected  in  the  presence  of 
any  real  illness  or  even  clanger  of  infection. 

Mode  of  obviating  ill  effects.— Ill  effects  appear  to 

be  associated  to  some  extent  with  the  amount  of  serum 
used  for  an  injection,  a  large  dose  being  more  likely  to  be 
followed  by  rashes,  etc.,  than  a  small  one.  There  is  thus 
reason  to  hope  that  the  occurrence  of  these  symptoms  will 
become  less  and  less  frequent  with  the  course  of  time,  since, 
as  it  becomes  possible  to  prepare  serums  of  increasing  anti- 
toxic strength,  smaller  doses  will  be  required  to  produce 
the  desired  effects.  Thus  diphtherial  antitoxin  has  been  pre- 
pared containing  as  much  as  1,500  units  to  the  cubic  centi- 
metre, a  comparatively  small  quantity  of  such  a  potent 
remedy  being  necessary  for  any  one  injection.  Attempts 
have  also  been  made  to  separate  the  antitoxin  from  the  rest  of 
the  serum  by  precipitating  the  globulin  and  utilizing  this 
for  injection.  Certain  horses  whose  serum  exhibits  specially 
toxic  qualities  should  not  be  used  for  the  preparation 
of  serum.  Horse-serum  is  said  to  be  most  toxic  when 
freshly  drawn,  and  gradually  to  lose  some  part  of  its  irri- 
tating qualities.  Heating  the  serum  to  60°  C.  also  dimin- 
ishes its  toxicity,  while  previous  administration  of  calcium 
chloride  or  lactate  to  the  patient  diminishes  the  risk  of 
exudative  phenomena  (urticaria,  etc.).  Besredka 1  suggests 
the  measurement  of  the  toxicity  of  serums  by  estimating 
their  power  of  inducing  anaphylaxis.  His  method  of 
avoiding  the  occurrence  of  anaphylaxis,  which  consists  in 
the  administration  of  a  small  quantity  of  serum  and  thirty 
minutes  later  injecting  the  full  dose,  has  already  been 
described  (p.  47).  It  is  advisable,  if  possible,  to  give  a 
second  dose  of  serum  within  a  week  of  the  administration 
of  the  first  dose,  thus  anticipating  the  time  at  which 
anaphylaxis  occurs,  and  possibly  inducing  anti-anaphylaxis. 
The  latter,  when  once  induced,  appears  to  persist  for  an 
indefinite  period. 

1  Ann.  <lc  I'lnst.  Pasteur,  1907,  xxi.  777. 


CHAPTER   III 

BACTERIAL   VACCINES:    THEIR   PREPARATION 
AND    ADMINISTRATION 

Theory  of  vaccine l  treatment. — The  administration  of 
bacterial  cultures  for  purposes  of  prophylaxis  is  a  pro- 
cedure which  is  easily  explicable  on  ordinary  principles, 
since  the  introduction  of  a  dose  of  virus,  which  the  in- 
dividual is  capable  of  overcoming  by  means  of  his  natural 
powers  of  resistance,  ensures  a  supply  of  antibodies  being 
formed  to  resist  subsequent  attack  by  the  infective 
organisms,  or,  more  probably,  educates  the  tissue-cells  to 
throw  off  a  large  supply  of  such  bodies  on  stimulation 
— since  to  confer  active  immunity  it  is  necessary  to  intro- 
duce the  specific  virus  into  the  individual  to  be  immunized. 

At  the  same  time,  it  is  evident  that  to  introduce  the 
infective  material  into  a  person  or  animal  by  the  same 
channel  as  that  by  which  infection  is  produced  in  the 
naturally  acquired  disease  would  merely  induce  the  very 
condition  from  which  it  is  sought  to  gain  protection.  Some 
other  method  must  be  selected.  Several  different  ways 
of  inoculation  without  conveying  an  actual  attack  of  the 
disease  are  available  : — 

1.  It  is  possible  to  inoculate  attenuated  virus,  i.e. 
bacteria  which  have  lost  some  of  their  power  of  produc- 
ing disease.  Attenuation 2  may  be  brought  about  (a)  by 

1  The  word  vaccine  is  used  on  the  analogy  of  the  original 
discovery  by  Jenner,  the  principle  being  the  same  in  the  modern 
procedures.  Wright  has  defined  a  vaccine  as  any  substance  which 
induces  in  the  organism  an  elaboration  of  protective  bodies. 

-  The  employment  of  organisms  attenuated  by  passage  through 
animals  has  been  called  "  Jennerization "  ;  the  use  of  chemical  and 
other  methods  of  weakening  their  virulence,  "  Pasteurization." 

o'J 


GO         SERUMS,    VACCINES,    AND    TOXINS 

growing  the  germs  under  conditions  unfavourable  to  their 
development :  anthrax  bacilli  grown  at  a  temperature  of 
40°  C.  lose  much  of  their  virulence,  and  Pasteur  made  use 
of  this  method  for  preparing  a  vaccine  for  the  protection  of 
animals  against  this  disease;  (6)  by  addition,  to  cultures  of 
the  organisms,  of  chemical  substances  inimical  to  their 
growth  :  thus  tetanus  toxin  may  be  attenuated  by  means  of 
iodine  trichloride  for  the  purpose  of  the  first  inoculations 
made  in  a  horse  in  the  preparation  of  an  antitoxin  ;  (c)  by 
heating  the  cultures  of  the  organisms,  as  in  the  case  of  the 
vaccines  for  black-leg  in  cattle ;  (d)  by  drying,  as  in  the 
case  of  the  spinal  cords  of  rabbits  used  in  inoculation 
against  hydrophobia  (but  see  below,  5) ;  (e)  by  passage  of 
the  infective  material  through  an  animal  which  has  a 
greater  power  of  resistance  to  it  than  man,  as  in  the 
case  of  small-pox,  which  in  the  cow  takes  the  form  of  the 
mild  disorder,  vaccinia  ;  (/)  by  passage  through  an  animal 
which,  although  it  is  as  sensitive  as  man  or  even  more  so, 
yet  alters  in  some  way  the  properties  of  the  virus,  so  that 
it  is  less  adapted  to  cause  human  infection  :  thus  it  is  said 
that  the  virus  of  hydrophobia,  after  passage  through  a 
series  of  rabbits,  although  its  virulence  for  these  animals 
is  immensely  increased,  is  yet  rendered  less  potent  for 
mankind. 

2.  The  dead   bodies  of  the   bacteria    may   be  injected 
instead  of  the  living  germs.     This  method  is  adopted  in 
Wright's  antityphoid  vaccination  and  in  the  treatment  of 
affections  due  to  staphylococci,  gonococci,  Bacillus  coli,  and 
other  organisms. 

3.  The  bacteria  may  be  inoculated  in  some  special  way, 
different  from  that  by  which  they  normally  enter  the  body 
to  cause  infection.     Thus  cholera  germs   may  be  injected 
hypodermically,  instead  of  reaching  the  alimentary  tract  by 
the  mouth,  as  they  do  in  cases  of  natural  infection.     The 
bacillus  of  black-leg  (Rauschbrand)  may  be  inoculated  sub- 
cntaneously  or  intravenously  for  purposes  of  protection,  its 
natural   seat    being    the    muscles.     The   tail    is   sometimes 


ATTENUATION   OF  VIRUS  61 

chosen  as  a  site  of  inoculation  in  animals,  as  being  colder 
than  the  rest  of  the  body  and  poorly  supplied  with  blood. 

4.  An   injection   of   antitoxic    serum    may    at  first   be 
administered  along  with  the   virulent  organisms,  so  as  to 
neutralize  part  of  their  toxins  until  the  animal  has  gained 
for  itself  the  power  of  manufacturing  antagonistic  bodies. 
This  method  has  been  used  by  Sobernheim  in  inoculation 
against  anthrax,  and  by  others  against  cattle-plague  and 
swine-erysipelas. 

5.  A  similar  result  may  be  attained    by  the  inocula- 
tion of   a  very  small   number  of  virulent   germs,  so   that 
the  patient  can  overcome  them   naturally,  whereas   grave 
infection  would  be  induced  by  a  larger  number  of  organ- 
isms.    This  is  the  principle  of  Hogyes'  vaccination  against 
rabies,  in  which  a  diluted  virus  is  employed.     It  is    not 
improbable  that  this  is  practically  the  basis  of  Pasteur's 
method  in  that  disease,  a  certain  number  of  the  infective 
agents — those  present  in  the  external  portion  of  the  spinal 
cord — being  killed  by  the  desiccation,  rather  than  all  those 
present  being  reduced  in  virulence. 

6.  The  bacteria  may  be  "  sensitized,"  before  injection,  by 
treatment  with  the  copula  or  immune  body  of  their  specific 
bactericidal  serum,  the    complement   being  previously   de- 
stroyed by  heat.     Besredka1  has  made  use  of  this  method  in 
vaccinating  animals  against  the  organisms  of  plague,  cholera, 
and    enteric   fever  ;    and    Barie 2  has    employed    a   similar 
method  in  the  case  of  rabies.     It  is  claimed  that  by  this 
procedure  the  primary  disagreeable  effects   of   vaccination 
are  avoided. 

In  many  cases  (not  small-pox)  there  appears  to  be  a  risk 
in  undertaking  protective  injections  in  the  presence  of  an 
actual  epidemic  of  the  disease,  since  during  the  first  few- 
days  after  inoculation  the  cells  of  the  body  tend  to  form  an 
excess  of  receptoi^s  (p.  24) ;  thus,  by  offering  more  points 
of  attachment,  the  cells  are  rendered  more  susceptible  to  the 

l  Ann.  de  Vlnst.  Pasteur,  1902,  xvi.  918. 

-  Compt.  Send.  Soc.  de  Biologie,  Dec.  5,  1902. 


62         SERUMS,    VACCINES,    AND    TOXINS 

toxins  of  the  disease ;  whilst  the  cells  have  not  yet  formed 
such  an  excess  as  to  cause  the  discharge  of  free  receptors 
into  the  serum. 

In  diseases  which  have  a  comparatively  short  incubative 
period  it  is  necessary  to  administer  the  vaccine  before 
infection  has  occurred.  In  small-pox,  vaccination  at  the 
time  of  infection  may  probably  exercise  an  effect  in 
modifying  the  disease,  since  the  incubative  period  of 
vaccinia  (about  four  days)  is  shorter  than  that  of  small-pox 
(twelve  days).  In  hydrophobia  the  latent  period  is  so  long 
that  it  has  been  found  possible  to  produce  the  immunity 
after  the  patient  has  been  infected  with  the  disease,  but 
before  the  symptoms  have  appeared.  This  is  the  principle 
of  Pasteur's  antirabic  inoculation,  of  the  protective  value  of 
which  there  can  now  be  no  reasonable  doubt  (see  p.  171). 

The  use  of  vaccine  as  treatment  for  existing  infection 
is  not  so  readily  intelligible.  It  might  be  argued  that  as 
living  germs  were  already  present  in  the  body,  giving  rise 
to  poisonous  products,  the  injection  of  more  of  the  same 
kind  of  germ,  dead  or  alive,  would  merely  add  to  the 
intoxication  and  so  intensify  the  disease. 

But  in  the  case  of  local  infections  the  bacteria  establish 
themselves  at  a  particular  spot  in  a  tissue  which  has  little 
resistance,  i.e.  little  power  of  producing  antibodies,  and  the 
injection  of  a  vaccine  in  some  healthy  distant  situation 
may  stimulate  the  formation  of  such  bodies  elsewhere ; 
they  may  then  be  brought  to  the  infected  focus  by  the 
blood,  provided  that  there  is  a  free  supply  of  lymph 
transuding  into  the  affected  part.  Such  an  influx  of 
lymph  is  aided  by  local  hypersemia,  the  production  of 
which  is  the  object  of  such  therapeutic  measures  as 
fomentations  and  Bier's  passive  congestion. 

In  the  case  of  a  septicaemia,  a  disease  in  which  the 
infective  organisms  are  carried  all  over  the  body  by  the 
blood-stream,  tKis  argument  has  at  firs.t  sight  but  little 
theoretical  weight,  and  we  have  to  admit  both  that  the 
basis  of  the  treatment  is  largely  hypothetical  and  that 


63 

« 

the  results  obtainable  by  this  mode  of  treatment  are  still 
a  matter  of  controversy.  Vaccine  treatment  of  enteric 
fever,  pneumonia,  puerperal  septicaemia,  and  malignant 
endocarditis,  for  example,  has  not  yet  been  established 
on  a  secure  basis.  So  far,  it  can  only  be  suggested  in 
its  favour,  by  way  of  theoretical  support,  that  while 
bacteria  are  not  apparently  destroyed  in  the  circulating 
blood,  they  may  be  present  in  this  fluid  without  settling 
in  those  particular  tissues  which  have  the  power  of  forming 
antibodies ;  whereas  dead  bacteria  introduced  under  the 
skin  may  be  carried  to  such  tissues  and  stimulate  them 
to  activity,  being  also,  perhaps,  more  easily  dealt  with 
by  these  tissues  than  are  the  living  germs,  owing  to  lack  of 
virulence  (absence  of  aggressins  or  of  the  power  of  forming 
a  protective  capsule).  An  alternative  explanation,  sug- 
gested by  the  experiments  of  Faginoli,1  is  that  the 
mechanism  of  vaccine-therapy  belongs  to  the  field  of  anti- 
anaphylactic  phenomena. 

PREPARATION  OF  BACTERIAL  VACCINES 

For  all  practical  purposes  these  vaccines  may  be 
regarded  as  suspensions  containing  intracellular  toxins  in 
combination  with  bacterial  protoplasm,  and  the  results 
obtained  by  their  employment  depend  on  the  activity  of 
these  toxins  and  the  quantity  present  in  the  vaccine. 
Such  vaccines  may  contain  (a)  bacteria  in  the  "  living " 
condition,  either  unaltered,  attenuated,  or  "  sensitized  "  by 
combination  with  homologous  immune  body;  or  (6)  bacteria 
which  have  been  destroyed,  in  some  cases  after  preliminary 
sensitization,  by  chemical  reagents,  heat,  or  other  physical 
agency.  A  vaccine  may  be  "autogenous,"  that  is,  prepared 
from  that  particular  strain  of  the  bacterium  already  pro- 
ducing the  infection  of  the  patient;  or  "stock,"  that  is,  one 
prepared  from  another  bacterium  of  the  same  species,  but 
already  stored  in  the  laboratory,  or  recently  isolated  from 
another  individual  suffering  from  an  apparently  identical 
1  II  Morgagni,  Oct.  31.  1915. 


64         SERUMS,   VACCINES,    AND   TOXINS 

+ 

infection.  However,  a  few  general  principles  may  at  once  be 
laid  down  with  regard  to  their  preparation.  In  the  first  place, 
there  is  a  consensus  of  opinion  that  as  the  passage  of  an 
organism  through  the  body  of  each  individual  host  modifies 
to  a  greater  or  less  extent  its  biological  characters  (resulting 
in  the  establishment  of  a  number  of  "strains"  of  that 
organism),  the  best  results  will  be  obtained  by  utilizing 
an  autogenous  rather  than  a  stock  vaccine.  The  truth  of 
this  principle  is  borne  out  by  the  experience  of  numerous 
observers,  although  it  is  more  obvious  in  some  instances 
than  in  others.  For  example,  in  an  infection  with  B.  coli  it 
is  futile  to  treat  the  patient  with  a  stock  vaccine ;  but,  on 
the  other  hand,  a  chronic  gonorrhoeal  arthritis  will  often 
rapidly  improve  under  treatment  with  a  stock  preparation. 
In  some  cases  the  preparation  of  an  autogenous  vaccine 
is  a  matter  of  great  difficulty,  if  not  of  impossibility,  as 
ill  the  chronic  arthritis  already  instanced,  owing  to  the 
difficulty  of  isolating  the  responsible  organism  ;  but  it 
should  always  be  attempted,  although  a  stock  vaccine  may 
be  utilized  during  the  interval. 

Secondly,  the  organism  must  be  as  virulent  as  possible, 
and  to  retain  this  character  the  subcultivations  used  in  the 
preparation  of  the  vaccine  must  not  be  far  removed  from 
the  body  of  the  patient.  In  other  words,  the  isolation  of 
the  bacterium  from  the  morbid  material  must  be  effected 
as  rapidly  as  possible,  and  in  as  few  generations  as  is  con- 
sistent with  obtaining  it  in  a  state  of  purity.  Hence  an 
extensive  knowledge  of  the  food-requirements  of  the  various 
pathogenic  bacteria  must  be  brought  to  bear  upon  the  tech- 
nique of  the  process  of  isolation. 

Next,  the  particular  subcultivation  intended  for  the 
production  of  the  vaccine  must  be  cultivated  under  "opti- 
mum "  conditions  as  to  composition  and  reaction  of  the 
medium  itself,  temperature  and  atmospheric  surroundings, 
age,  and  so  forth ;  and  the  emulsion  prepared  from  this  sub- 
culture must  be  made  with  an  indifferent  fluid,  and  must  be 
perfectly  homogeneous  and  capable  of  sufficiently  accurate 


PREPARATION   OF   VACCINES  65 

standardization  to  ensure  subsequent  facility  of  dosage. 
Now,  in  the  case  of  the  "  killed  "  vaccine,  the  vitality  of  the 
bacteria  contained  in  the  emulsion  must  be  totally  destroyed 
by  a  lethal  agent  causing  the  least  possible  alteration  in 
the  molecular  arrangement  of  the  bacterial  protoplasm — 
that  is  to  say,  the  power  of  vegetative  multiplication  must 
be  effectually  removed  from  the  bacteria,  but  complete 
coagulation  of  the  protoplasm  should  be  avoided.  If  heat 
is  employed  to  attain  this  end,  it  is  necessary  to  know 
accurately  the  thermal  death-point,  in  watery  emulsion,  of 
the  organism  under  treatment,  and  to  conduct  the  opera- 
tion of  killing  the  bacteria  at  that  temperature  for  as  short 
a  period  as  will  attain  the  desired  end.  Other  agents  are 
sometimes  employed,  such  as  a  weak  solution  of  carbolic 
acid,  or  lysol,  or  sodium  fluoride.  Finally,  after  killing 
the  bacteria,  it  is  customary  to  adjust  the  strength  of  the 
vaccine  to  some  convenient,  although  empirical,  standard, 
and  to  add  sufficient  antiseptic  to  ensure  the  continued 
sterility  of  the  emulsion. 

The  actual  process  of  preparing  a  vaccine  is  briefly  as 
follows,  it  being  understood  that  all  apparatus  and  reagents 
employed  in  the  process  have  been  sterilized. 

The  organism  responsible  for  some  given  infection,  having 
been  isolated  from  the  lesion  existing  in  the  patient  and 
identified,  is  planted  upon  a  suitable  medium,  either  in  tubes 
to  form  tube-cultures,  or  better  in  a  Roux  or  similar  bottle 
to  form  "  mass  "-cultures,  and  is  incubated  under  optimum 
conditions  for  such  period  of  time  as  experience  shows  is 
calculated  to  yield  the  maximum  number  of  vigorous  living 
bacteria. 

At  the  end  ,of  the  cultivation  period  the  growth  is 
examined  visually  to  determine  its  freedom  from  gross 
contamination,  and  by  means  of  stained  preparations  to 
determine  its  purity.  The  culture  proving  satisfactory, 
5  c.c.  of  a  O'l  per  cent,  saline  (NaCl)  solution  are  pipetted 
into  the  tube  or  bottle,  and  the  growth  emulsified  as  evenly 
as  possible  with  the  help  of  a  glass  or  platinum  rod.  The 
F 


66         SERUMS,   VACCINES,    AND    TOXINS 

turbid  emulsion  is  transferred  to  a  stout  glass  test-tube 
containing  a  number  of  glass  beads  :  this  is  then  placed  in 
some  form  of  mechanical  shaker,  and  agitated  thoroughly 
for  about  a  quarter  of  an  hour. 

Standardization  of  vaccines. — The  amount  of  bac- 
terial protoplasm  present  in  every  cubic  centimetre  of  the 
emulsion  is  next  estimated  by  weighing,  or  by  counting 
the  actual  number  of  bacteria  in  a  hsemocytometer  chamber, 
or  by  Wright's  method.  Unfortunately  there  is  at  present 
no  special  method  which  has  obtained  general  acceptance ; 
indeed  some  workers  appear  to  standardize  these  vaccines 
merely  by  visual  inspection  of  the  density  of  the  emul- 
sion. Wright's  method  is  perhaps  the  one  even  now  in 
most  common  use;  it  consists  in  taking  equal  volumes 
of  blood  from  a  normal  individual  and  of  the  bacterial 
emulsion,  mixing  thoroughly,  spreading  in  a  thin  film  on  a 
glass  slide,  fixing  and  staining  with  Irishman's  or  Jenner's 
stain,  and  then  with  the  help  of  the  -jL-inch  oil-immersion 
lens  enumerating  the  numbers  of  red  cells  and  of  bacteria 
respectively  in  some  twenty-five  separate  "  fields  "  of  the 
microscope.  From  the  numbers  thus  recorded  an  average  is 
struck  and  the  ratio  the  red  blood-disks  bear  to  the  bacteria 
is  estimated.  Now,  assuming  that  normal  blood  contains 
5,000  millions  of  red  cells  per  cubic  centimetre,  a  simple  sum 
in  proportion  gives  the  number  of  bacteria  present  in  each 
cubic  centimetre  of  the  bacterial  emulsion. 

Having  determined  the  numerical  strength  of  the  vac- 
cine, a  sufficient  quantity  of  0-1  per  cent,  salt  solution  is 
added  to  the  emulsion  to  reduce  the  weight  of  protoplasm 
per  cubic  centimetre  to  some  convenient  fraction  of  a  milli- 
gramme, or  to  reduce  the  numbers  in  each  cubic  centimetre 
to  1,000  or  100  millions,  or  to  whatever  quantity  is  selected 
as  the  standard,  and  the  mixture  is  well  shaken.  The  tube 
is  then  suspended  for  a  period  of  thirty  minutes  in  a  water- 
bath  running  at  a  temperature  corresponding  with  the  ther- 
mal death-point  of  the  bacterium  employed  for  the  vaccine 
(e.g.  59°  to  GO0  C.  for  Slfiplrylococcns  aiireus).  After  removal 


SENSITIZED    VACCINES  67 

from  the  water-bath,  loopfuls  of  the  emulsion  are  sown 
upon  suitable  media,  and  incubated,  in  order  to  determine 
the  sterility  of  the  vaccine.  Finally,  a  small  quantity 
of  some  antiseptic,  such  as  0-5  per  cent,  carbolic,  0-25 
per  cent,  lysol,  or  0-25  per  cent,  trikresol,  is  added  to 
the  vaccine,  which  is  then  put  up  for  use  in  separate  doses 
in  small  glass  bulbs,  the  necks  of  which  are  sealed  in  the 
blowpipe,  or  in  bulk  in  rubber-capped  bottles.  In  the  latter 
case  the  requisite  dose  is  removed  from  the  bottle  by 
means  of  the  hypodermic  syringe,  the  needle  of  which  is 
made  to  pierce  the  rubber  cap  through  a  drop  of  pure 
lysol,  the  orifice  being  subsequently  sealed  with  rubber 
solution. 

Sensitized  vaccines.— A  modification  of  this  method 
of  preparation  was  introduced  by  Besredka  in  dealing 
with  vaccines1  for  prophylactic  use  against  cholera,  plague, 
and  enteric  fever,  in  which,  either  before  or  after  steriliza- 
tion by  heat,  the  bacterial  emulsions  were  mixed  with 
their  respective  antiserutns.  In  such  a  mixture,  after 
allowing  it  to  stand  for  some  twelve  hours,  it  could  be 
shown  that  the  bacilli  had  entered  into  combination  with 
the  specific  copula.  The  bodies  of  the  bacteria  were  then 
washed  free  from  serum  in  several  changes  of  physio- 
logical salt  solution,  and  standardized  as  already  described. 
Besredka  claims  that  with  these  sensitized  vaccines  active 
immunity  is  produced  in  the  inoculated  individual  almost 
immediately,  and  that  with  very  little  local  reaction  and 
practically  no  constitutional  disturbance. 

As  the  result  of  further  research  work,  Besredka  and 
Metchnikoff,  having  failed  to  immunize  the  chimpanzee 
with  heated  vaccines,  were  successful  in  their  attempts 
when  they  substituted  sensitized  living  cultures  of  the  ty 
phoid  bacillus — an  observation  which  prompted  Broughton- 
Alcock2  to  apply  the  same  principle  to  man  for  pro- 
phylactic vaccination,  and  subsequently  to  employ  sensi- 

1  Ann.  de  Vlnst.  Pasteur,  1902,  xvi.  916. 

8  Gnnipf  Rend.  Acnd.  Sciences,  May  17,  1012. 


68         SERUMS,    VACCINES,    AND    TOXINS 

tized  living  vaccines  of  the  pyogenic  cocci  in  the  treatment 
of  staphylococcic,  streptococcic,  and  gonococcic  infections. 
This  method  has  now  been  extended  to  include  the  treat- 
ment of  a  large  number  of  different  infections  in  the  human 
subject,  due  to  various  bacteria. 

The  difficulty  of  obtaining  specific  serums  for  the 
purpose  of  sensitizing  the  bacterial  cultures  has  been  over- 
come by  Broughton-Alcock  l  by  injecting  the  patient  first 
with  an  ordinary  vaccine  (sterilized  by  heat)  of  the  infect- 
ing micro-organism  and,  when  specific  amboceptors  can 
be  demonstrated  in  that  individual's  serum,  using  this 
serum  to  sensitize  the  living  vaccine — a  procedure  to  which 
the  term  "  double  method  "  has  been  applied. 

From  time  to  time  various  observers  have  advocated 
and  used  living  untreated  bacilli  as  vaccines.  Strong 2  in 
Manilla  employed  a  living  plague-vaccine  as  a  prophylac- 
tic measure,  without  untoward  consequences;  and  Bourke, 
Evans  and  Rowland3  have  administered  living  typhoid 
cultures  therapeutically,  with  apparently  good  results. 

Toxins  as  curative  agents, — The  intracellular  toxins 
of  the  tubercle  bacillus  have  been  used  by  Koch  as  a  curative 
agent,  under  the  name  of  "  tuberculin."  It  was  found  that 
the  injection  of  this  substance  caused  a  distinct  reaction  at 
the  seat  of  tubercular  lesions  such  as  lupus,  and  that  the 
inflammation  thus  produced  seemed  to  act  beneficially  on 
the  course  of  the  disease.  In  the  case  of  the  "new  tuber- 
culin "  the  toxic  bodies  of  the  bacteria  are  dissolved  and 
injected,  with  the  view  of  strengthening  the  patient's 
resistance  to  the  disease  (see  p.  273). 

A  similar  preparation  from  the  glanders  bacillus, 
termed  "  malleln,"  has  also  been  employed  therapeutically 
in  a  case  of  glanders  in  man,  but  without  beneficial  result. 

A  trade  preparation  consisting  of  mixed  sterile  filtrates 

1  Immunity  Section,  Seventeenth  Congress  of  Medicine,  1913. 

2  Quoted  by  Marx,  "  Diagnostik,  Serumtherapie  und  Prophylaxe," 
p.  81. 

*  Brit.  Mrd.  J»vrn.t  1915,  ii.  587. 


EFFECTS    OF   VACCINES  69 

from  broth-cultivations  of  a  variety  of  micro-organisms, 
such  as  staphylococci,  streptococci,  pneumococci,  B,  coli, 
B.  typhosus,  etc.,  is  sold  under  the  name  of  "  phylacogen." 
This  is  stated  to  be  of  value  in  the  treatment  of  many 
bacterial  infections,  including  rheumatism.  Fortified  by 
the  addition  of  filtered  culture-fluid  in  which  some  specific 
bacterium  has  been  grown,  it  is  advertised  for  use  in  infec- 
tions due  to  that  particular  organism — i.e.  gonorrhoea- 
phylacogen  for  gonorrhoea.  Such  a  hotch-potch  is  quite 
unscientific,  and,  as  the  organisms  employed  are  those 
which  are  ordinarily  incapable  of  producing  any  appreciable 
amount  of  exotoxiu  in  broth- cultivations,  phylacogen  re- 
solves itself  into  a  solution  of  altered  protein  more  or 
less  toxic  in  itself,  and  its  injection  into  the  human  subject 
is  a  procedure  which  is  not  only  useless  but  under  certain 
circumstances  may  be  dangerous. 

Phenomena  accompanying  active  immunization 

by  vaccines.— The  immediate  result  of  the  introduction 
of  a  suitable  dose  of  vaccine  into  the  tissues  of  a  patient  is 
a  fall  in  the  amount  of  opsonin  present  in  the  serum,  owing 
presumably  to  the  linking-up  of  some  of  the  available 
opsonin  to  the  bodies  of  the  bacteria  introduced.  This  is 
termed  the  "negative  phase"  (Fig.  10),  and  occupies  a 
period  lasting  from  a  few  hours  to  a  week  or  ten  days,  or 
in  exceptional  cases  a  fortnight  or  more.  Its  duration  is 
increased  by  a  larger  dose,  and  reduced,  or  even  elimin- 
ated altogether,  by  a  smaller  dose. 

As  a  result  of  the  stimulus  provided  by  the  successful 
use  of  a  vaccine,  fresh  supplies  of  opsonin  are  elaborated 
and  discharged  into  the  serum,  and  the  negative  phase  is 
succeeded  by  a  ".positive  phase,"  during  which  the  opsonic 
index  rises  slowly  or  rapidly  to  a  maximum,  after  which 
it  frequently  oscillates  slightly  for  a  day  or  two,  and 
then  comes  to  rest,  and  a  condition  of  "  equilibrium  "  is 
established,  in  which  the  index  is  maintained  at  a  higher 
level  than  it  occupied  before  the  injection,  although  even 
now  not  necessarily  at  or  above  the  normal.  This  state  of 


70         SERUMS,    VACCINES,    AND    TOXINS 

equilibrium,  after  a  period  varying  with  different  individuals, 
with  the  size  of  the  dose,  etc.,  declines  either  gradually  or 
rapidly  until  it  has  fallen  to,  or  below,  its  original  position. 
A  repetition  of  the  dose  of  vaccine  now  causes  a  repetition  in 
their  entirety  of  the  phenomena  already  detailed.  If,  how- 


Fig.  10.— The  opsonic  cycle,     (lu  this  and  the  following  figure  the 
arrow  indicates  au  iiijection.) 

ever,  a  second  dose  of  vaccine  is  administered  during  the 
negative  phase  induced  by  the  first  injection,  a  cumulative 
action  is  noted,  and  a  second  negative  phase  is  superposed 
on  the  first :  the  opsonic  index  will  then  rapidly  fall,  perhaps 
with  serious  results  to  the  patient  (Fig.  11).  On  the  other 
hand,  a  second  dose  injected  at  the  highest  point  of  the 
positive  phase  will  not  in  most  instances  give  rise  to 
cumulation  of  positive  phases  (although  in  some  infections 


in 


Fig.  11. — Opsonic  index,  showing  rapid  fall. 

— for  example,  those  due  to  the  gonococcus,  Bacillus  coli 
etc. — this  highly  desirable  end  can  be  obtained).  Usually 
such  a  procedure  merely  results  in  a  shorter  or  less  marked 
negative  phase  (Fig.  12).  Practically  it  is  found  that 
good  clinical  results  are  obtained  if  the  index  oscillates 
about  the  normal  level,  provided  that  the  greater  part 
of  the  curve  representing  the  movements  of  the  index 


EFFECTS    OF   VACCINES  71 

is  above  normal  (Fig.  13).  Consequently,  to  obtain  the 
best  results  by  the  aid  of  vaccines,  subsequent  doses  should 
be  injected  towards  the  end  of  the  period  of  equilibrium. 


Fig.  12.— Opsonic  index,  showing  less  marked  negative  phase. 

Endeavour  should  be  made  so  to  adjust  the  dose  as  to  obtain 
the  shortest  negative  phase  compatible  with  the  production 
of  a  positive  phase  lasting  from  five  to  seven  days. 

In   many   acute   infections,  however,   it  is   of   greater 
importance  to  reduce  or  eliminate  the  negative  phase  which 


V 


Fig.  13. — Opsonic  index,  showing  oscillation  about  normal  level. 

follows  the  injections  than  to  lengthen  the  positive  phase  ; 
and  a  dose  must  be  administered  so  minute  that  the  positive 
phase  appears  almost  immediately  ;  and  must  be  repeated 
before  the  transient  positive  phase  has  declined — some- 
times within  twelve  hours  (Fig.  14). 


7 


V  V 


Fig.  14. — Opsonic  index,  showing  immediate  appearance  of 
positive  phase. 

Similar  observations  have  been  recorded  in  connection 
•with  other  antibodies,  particularly  agglutinins. 


72         SERUMS,   VACCINES,    AND    TOXINS 

ADMINISTRATION  OF   VACCINES 

General  considerations. — Practically  every  case  of 
bacterial  infection  presents  points  of  peculiarity,  and 
although  it  is  impossible  to  lay  down  any  hard-and-fast 
rule  for  the  dosage  or  administration  of  vaccines,  a  few 
general  considerations  can  be  stated  as  the  result  of 
experience  accumulated  by  many  workers  during  the  past 
ten  years. 

The  first  essential  is  that  the  diagnosis  should  be 
accurate,  and  that  full  and  complete  information  should  be 
available  as  to  the  exact  organism  responsible  for  the 
infection,  since  the  futility  of  treating  a  streptococcus 
infection  with  a  staphylococcus  vaccine  is  sufficiently 
obvious. 

The  estimation  of  the  opsonic  index  is  not  absolutely 
essential  for  the  successful  conduct  of  treatment,  careful 
attention  to  clinical  signs  and  symptoms,  temperature 
reactions,  and  local  condition  being  in  most  instances 
sufficient  guide  for  the  administration  of  vaccine  in  the 
acuter  forms  of  bacterial  infection.  Thus,  during  the 
negative  phase,  although  no  appreciable  rise  of  tem- 
perature occurs  (unless  an  excessive  dose  has  been 
administered),  the  patient  sometimes  complains  of  not 
feeling  well,  and  any  local  lesion  that  may  be  present  is 
objectively  worse — the  discharge  from  a  sinus  increases  in 
amount ;  in  a  cystitis  there  is  an  increase  in  frequency  of 
micturition,  and  more  pus  is  present  in  the  urine;  in 
furunculosis^  a  fresh  crop  of  boils  may  appear,  and  so  on — 
whilst  during  the  ensuing  positive  phase  a  subjective  sense 
of  well-being  is  experienced,  pyrexia  diminishes,  often 
rapidly,  and  clinically  the  improvement  is  marked.  In  the 
subacute  and  chronic  types  of  infection  the  weighing 
machine  is  a  useful  adjunct  to  clinical  observation. 

When  undertaking  vaccine  treatment  without  the 
assistance  of  the  opsonic  index,  the  initial  doses  must  be 
small,  in  order  to  avoid  the  risk  of  a  negative  phase 


ADMINISTRATION   OF   VACCINES  73 

excessive  in  amount  or  duration.  Then,  too,  the  age, 
weight,  and  general  condition  of  the  patient  must  to  a 
certain  extent  be  taken  into  consideration.  Speaking 
generally,  an  emaciated  infant  or  an  enfeebled  and  elderly 
patient  would  receive  a  very  much  smaller  dose  than 
a  well-developed  and  apparently  vigorous  adult.  With 
acute  and  generalized  infections  the  initial  dose  should 
be  very  small  indeed,  perhaps  not  more  than  one  million 
bacteria,  but  in  subacute  infections  it  may  well  be 
ten  times  as  large,  and  in  chronic  conditions  a  hundred 
times  as  large.  Again,  so  long  as  improvement  is  main- 
tained with  any  given  dose,  it  may  be  stated  in  general 
terms  that  there  is  no  object  in  increasing  that  dose. 
With  most  vaccines,  however,  it  will  be  found  that  after  a 
time  any  given  dose  is  incapable  of  provoking  a  response 
equal  to  that  at  first  obtained,  and  then  it  is  necessary  to 
alter  the  dose  from  that  originally  determined  ;  and  similar 
changes  will  be  needed  throughout  the  whole  course  of 
treatment. 

It  should  be  remembered,  too,  that  a  dose  sufficiently 
large  to  provoke  constitutional  disturbance  and  pyrexia 
usually  goes  hand  in  hand  with  a  negative  phase  of 
considerable  extent.  Pyrexia  should,  therefore,  be  an  indi- 
cation for  making  the  ensuing  dose  very  much  smaller  in 
size. 

Carefully  conducted  surgical  treatment  should  accom- 
pany the  vaccine  treatment  throughout.  Thus,  whenever 
possible,  an  infected  area  should  be  immobilized,  an 
infective  focus  removed,  and  so  on. 

The  Syringe. — The  vaccine  syringe  should  be  of  the 
all-glass  type  similar  to  that  used  for  serum-injection,  but 
of  1  c.c.  capacity,'  graduated  on  the  barrel  in  tenths  and 
twentieths.  The  piston,  if  made  of  blue  or  amber  glass, 
renders  the  process  of  subdividing  doses  an  easy  matter. 
The  ordinary  steel  hypodermic  needle  is  to  be  preferred  to 
the  platino-iridium  needle,  since  as  a  general  rule  it  is  finer 
and  takes  a  sharper  point,  whilst,  being  less  costly,  it  can 


74         SERUMS,    VACCINES,    AND   TOXINS 

be  replaced  frequently  at  no  great  expense.  Syringe  and 
needle  are  best  sterilized  by  boiling  immediately  before  use, 
though  some  prefer  to  draw  up  into  the  syringe  boiling 
olive  oil  and  then  eject  it. 

Site  of  inoculation. — Theoretically,  the  dose  of 
vaccine  may  be  injected  into  loose  subcutaneous  tissue 
wherever  situated  in  the  body,  but  practice  has  shown  that 
some  sites — usually  those  poorly  supplied  with  cutaneous 
nerves — are  preferable  to  others ;  thus  injections  into  the 
arm  or  leg,  where  the  subcutaneous  tissue  is  scanty  and 
the  movement  of  the  underlying  muscles  frequent  and 
unavoidable,  tempting  though  such  situation  may  be  on 
account  of  the  accessibility,  should  be  sedulously  avoided. 
Vaccines  should  not  be  given  by  the  mouth  or  by  the 
rectum.  The  best  situations  are  the  subcutaneous  tissue 
underlying  the  anterior  abdominal  wall,  or  in  the  flank ;  at 
a  point  about  an  inch  below  the  centre  of  the  clavicle ; 
below  the  point  of  the  scapula;  on  either  side  of  the 
middle  line  between  the  scapulae ;  along  a  line  about  an 
inch  above  and  parallel  to  the  spine  of  the  scapula ;  or  at 
the  base  of  the  mammae.  The  skin  over  the  selected  area 
should  be  washed  with  ether  or  acetone,  or  painted  with 
tincture  of  iodine.  Concentrated  disinfectants  such  as 
pure  lysol  should  not  be  employed. 

The  selected  dose  having  been  drawn  up  into  the 
syringe,,  a  fold  of  prepared  skin  should  be  pinched  up 
between  finger  and  thumb,  the  needle  plunged  boldly 
through  -it  into  the  subcutaneous  tissues  and  the  vaccine 
ejected  from  the  syringe,  the  needle  quickly  withdrawn, 
and  the  puncture  again  wiped  with  the  antiseptic  previously 
used.  No  dressing  of  the  puncture  is  needed. 

ADDENDUM 

Use  Of  lactie-acid  bacilli.— Metchnikoff's  suggestion,  that  by 
the  ingestion  of  cultures  of  Ji.  buJyarieiis  the  more  noxious  denizens 
of  the  intestinal  tract  might  be  crowded  out,  led  to  a  large  number  of 
experiments  in  the  use  of  this  treatment  in  a  variety  of  alimentary 


LACTIC-ACID   BACILLI  75 

and  intestinal  diseases,  but  the  results  have  not  come  up  to  the  hopes 
that  were  first  aroused.  In  obstinate  conditions  of  disturbance  of  the 
intestinal  functions,  however,  when  other  means  fail,  the  method  is 
worthy  of  trial. 

Local  use  of  cultures  of  lactic-acid  bacilli  has  been  recommended 
by  North l  in  conditions  of  the  mucous  membranes.  He  reports  very 
good  results  in  cases  of  atrophic  rhinitis  (56  cases,  50  improved) ; 
his  statistics  of  results  in  other  conditions,  such  as  otitis  media, 
leucorrhcea  and  gonorrhoea,  are  not  very  striking.  Two  cases  of 
acute  diffuse  peritonitis  are  stated  to  have  been  successfully  treated 
by  this  means,  which  has  also  been  employed  for  suppurating  wounds 
and  bruises.  Persson2  records  successful  results  in  28  out  of  36 
gonorrhoeal  cases ;  and  Newman 3  records  the  use  of  intravesical 
injections  in  the  treatment  of  cystitis. 

Lactic-acid  bacilli  have  also  been  used  as  a  spray  with  a  view  to 
dislodging  persistent  diphtheria  bacilli  from  the  fauces.4  For  this 
purpose  a  spray  of  staphylococci  has  also  been  employed,  but  this 
organism  is  pathogenic  and  may  give  rise  to  tonsillitis,5  hence  its 
employment  would  seem  to  be  dangerous  and  unjustifiable. 

1  Med.  Record,  1909,  Ixxv.  509. 

2  Ibid.,  1910,  Ixxviii.  534. 

3  Lancet,  1915,  ii.  330. 

4  Jotirn,  Amer.  Med.  Assoc.,  1913,  p.  392. 
6  Davis,  ibid.,  1914,  Ixi.  393. 


CHAPTER  IV 
SERUMS   AND   TOXINS    IN    DIAGNOSIS 

AGGLUTINATION  TESTS 

THE  first  observations  on  the  agglutinating  power  which 
the  serum  derived  from  patients  suffering  from  certain 
infective  diseases  exerts  on  the  bacteria  causing  the  con- 
dition were  made  by  Gruber  and  Durham  with  regard  to 
the  reaction  as  it  affects  the  bacilli  of  enteric  fever.  It  was 
afterwards  found  that  very  many  kinds  of  micro-organism 
were  similarly  affected  by  the  serum  of  animals  immunized 
against  them,  but  it  will  be  more  convenient  to  discuss  the 
rationale  of  the  test  in  connection  with  the  B.  typhosus. 

Enteric  fever. — The  reaction  was  first  suggested  as  a 
practical  test  for  diagnosis  of  enteric  fever  by  Widal  in 
1896,  although  experiments  in  this  direction  had  previously 
been  made  by  Grunbaurn  :  the  latter  were  not  published 
till  after  Widal's  communication.  The  "  test "  may  there- 
fore fairly  be  called  "  Widal's,"  although  he  was  not  the 
discoverer  of  the  phenomenon.  A  very  large  amount  of 
experience  is  now  available  as  to  the  occurrence  of  the 
"  reaction  "  in  cases  of  enteric  fever. 

At  first  it  was  thought  that  the  mere  fact  that  the 
serum  of  a  patient  possessed  the  clumping  property  was 
conclusive  evidence  that  the  disease  from  which  he  was 
suffering  was  enteric  fever ;  but  it  was  soon  found  that  the 
serum  of  many  normal  persons  was  capable  of  producing 
the  same  effect.  That  derived  from  typhoid  patients, 
however,  is  much  more  strongly  agglutinative  than  normal 
serum,  and  will  produce  the  reaction  even  if  considerably 
diluted  (e.g.  1  :  200).  The  test  as  at  first  described  was 

76 


WIDAL   TEST  77 

therefore  modified,  a  serum  diluted  by  mixture  with  nine 
times  its  volume  of  normal  saline  solution  being  employed. 

It  is  now  recognized  that  a  dilution  of  1  : 10  is  not 
sufficient  to  exclude  a  number  of  cases  in  which  the  indi- 
vidual normally  possesses  a  somewhat  high  agglutinative 
power  without  any  present  infection  with  enteric  fever.  A 
dilution  of  1  :  50  is  therefore  taken  as  the  lowest  dilution 
from  which  to  judge  of  the  reaction  of  a  serum  in  suspected 
enteric  fever ;  if  such  a  diluted  serum  causes  agglutination 
within  half  an  hour,  the  reaction  is  called  positive. 

Libman  l  states  that  a  positive  reaction  may  sometimes 
occur  in  high  dilutions  (1  :  500)  when  it  is  not  present 
in  more  concentrated  mixtures  (1  :  20)  ;  he  therefore 
recommends  the  use  of  two  dilutions  for  each  test 
(see  p.  81). 

Mode  of  performing  the  Widal  test.— The  blood 
of  the  patient  may  be  obtained  from  either  the  finger-tip  or 
the  lobe  of  the  ear.  The  latter  is,  perhaps,  the  better  of  the 
two,  as  it  is  less  sensitive,  and  the  blood  flows  quite  as  freely, 
if  not  more  so.  The  skin  should  be  cleaned  up  first  with 
lysol  or  similar  antiseptic,  and  afterwards  with  sterilized 
water  :  this  precaution  is  not,  however,  absolutely  necessary. 
The  lobule  of  the  ear  is  then  firmly  grasped  with  the  fingers 
of  the  left  hand,  and  a  deep  puncture  is  quickly  made  with 
a  sharp  surgical  needle,  or  with  a  special  instrument  made 
for  the  purpose.  A  common  needle  will  serve,  if  no  other 
is  available.  The  blood  is  collected,  as  it  exudes,  in  a  glass 
bulb  drawn  out  at  either  end  into  a  fine  point ;  the  ends  being 
sealed  in  a  flame  after  the  blood  is  collected.  In  the  tube 
coagulation  takes  place,  and  the  serum  which  exudes  from 
the  clot  is  ready  for  use.  It  is  advisable  to  dilute  the  serum 
itself  before  mixing  it  with  the  culture  of  bacilli,  and  not 
merely  to  use  the  latter  for  purposes  of  dilution ;  since  the 
pure  serum  may  produce  some  clumping  on  first  coming  into 
contact  with  the  bacilli,  before  the  whole  is  properly  mixed, 
and  errors  may  thus  arise.  For  dilution  of  the  serum, 
1  Med.  News,  Jan.  30,  1904,  p.  204. 


78         SERUMS,    VACCINES,    AND    TOXINS 

sterile  salt-solution  (0-6  per  cent.)  must  be  employed,  since 
in  the  absence  of  salt  the  reaction  may  fail. 

Several  different  ways  of  effecting  the  necessary  dilu- 
tion of  the  sei'um  are  employed.  It  is  best  to  use,  at  all 
events  for  the  higher  dilutions,  a  graduated  pipette,  which 
saves  time  and  trouble.  Some  sterile  neutral  fluid  such  as 
normal  saline  solution  is  used  for  the  purpose.  The  broth- 
culture  of  the  Bacillus  typhosus  must  be  a  recent  (eighteen 
to  twenty-four  hours  old)  and  vigorous  one,  in  which  the 
bacilli  are  moving  freely  about.  In  older  cultures  an  agglu- 
tinating substance  is  formed  by  the  bacilli  and  diffuses  out 
into  the  liquid  :  in  such  specimens  the  bacilli  are  found  to 
have  become  clumped  without  the  addition  of  any  extraneous 
material,  and  ai'e  therefore  unfit  for  use.  The  addition  of  a 
few  drops  of  an  old  culture  to  a  young  and  vigorously 
moving  emulsion  will  produce  agglutination.  It  is  well  to 
observe  the  condition  of  the  culture  before  using  it,  in  order 
to  see  what  (if  any)  degree  of  clumping  is  already  present. 

When  the  dilution  has  been  made  .and  the  bacilli  added 
to  it,  a  drop  of  the  mixed  fluid  is  placed  on  a  cover-glass, 
and  a  hanging-drop  preparation  is  made,  and  observed  under 
the  microscope  with  a  medium-power  objective.  The  cover- 
glass  should  be  ringed  round  with  vaseline  or  some  similar 
substance,  to  prevent  evaporation.  A  high  power  is  not 
necessary ;  indeed,  it  may  even  be  a  source  of  fallacy  to 
beginners,  by  leading  them  to  mistake  the  small  clumps 
which  are  present  in  almost  all  cultures  for  the  larger 
masses  which  form  as  the  result  of  the  true  agglutination. 
At  first  the  bacilli  can  be  seen  moving  actively  about 
in  all  directions,  but  their  movements  gradually  become 
more  sluggish  and  finally  cease,  while  the  organisms  may 
be  seen  to  become  aggregated  into  lumps  or  masses.  If  a 
true  agglutination  of  the  bacilli  takes  place,  it  will  be 
seen  that  almost  all  of  them  have  run  together  into 
masses,  while  any  that  remain  free  have  lost  their  mobility 
and  remain  stationary  in  the  field  of  the  microscope. 

A    time-limit    is    necessary    for   this    test,    and    half 


AGGLUTINATION   TEST  79 

an  hour  is  that  usually  taken.  If  within  this  time  the 
bacilli  have  all,  or  nearly  all,  ceased  to  move  and  become 
massed  together,  then  the  test  is  said  to  be  positive. 
Although  the  test  is  generally  conducted  at  room-tem- 
perature (about  20°  C.),  the  optimum  temperature  for 
agglutination  is  said  by  Weil l  to  be  60°-65°  C. 

The  test  may  also  be  done  macroscopically,  by  mixing 
the  serum  and  culture  in  a  watch-glass.  A  visible  pre- 
cipitate falls  if  the  reaction  is  positive.  According  to 
Berliner  and  Cohn,2  a  star-like  figure  is  seen  in  a  watch- 
glass  in  half  an  hour  at  room-temperature. 

Another  way  of  making  use  of  the  agglutination  reaction 
for  diagnosis  is  to  add  a  measured  volume  of  serum  to 
a  known  quantity  of  culture  in  a  test-tube.  If  the  former 
possesses  agglutinative  properties  a  precipitate  forms  in  the 
tube,  visible  to  the  naked  eye  owing  to  the  subsidence  of 
the  clumped  bacteria  to  the  bottom  of  the  glass.  This  is 
known  as  the  "  sedimentation  test "  or  the  "  precipitation 
test."  It  is  also  possible  to  cultivate  organisms  in  the 
serum  and  to  compare  the  appeai-ances  which  they  present 
with  those  of  cultures  in  ordinary  serum.  In  some  cases  the 
growth  in  the  specific  serum  is  characterized  by  clumping  or 
by  formation  of  chains  or  threads  (Pfaundler's  reaction). 

McWeeney 3  has  devised  a  special  method  of  performing 
the  test,  by  growing  the  bacilli  in  hanging  drops,  one  with 
the  serum  to  be  tested,  the  other  with  normal  serum.  If 
the  reaction  is  positive,  the  bacilli  in  this  drop  will  be  seen  to 
form  chains  and  to  be  non-motile,  whereas  in  the  "control" 
experiment  they  are  separate  and  freely  motile.  The  serum 
is  added  in  the  proportion  of  1  per  cent.,  and  the  slides  are 
kept  at  37 °C. 

Hewitt  and  Rowland4  are  the  authors  of  a  means  of 
performing  an  exactly  graduated  quantitative  test.  The 

1  Prager  med.  Woch.,  1904,  No.  19,  p.  233. 
a  Milnch.  med.  Wock.,  Sept.  11,  1900. 
3  Dublin  Journ.  of  Med.  Science,  Sept.,  1898. 
*  fit-it.  MeiJ.  Journ.,  1900,  i.  1015. 


80         SERUMS,   VACCINES,    AND   TOXINS 

serum  is  received  into  capillary  tubes,  of  which  the 
thickness  of  the  walls  and  the  diameter  of  the  lumen  are 
measured  under  the  microscope,  while  the  length  of  tube 
which  is  filled  by  the  serum  is  easily  ascertained.  In 
this  way  the  exact  volume  of  serum  is  calculated,  and 
subsequent  dilution  is  effected  by  measured  proportional 
amounts  of  broth. 

Picker1  has  devised  a  method  of  performing  the  test 
with  dead  bacilli,  specially  prepared  and  suspended  in  an 
indifferent  fluid,  the  nature  of  which  has  not  been  published. 
The  serum  to  be  examined  is  diluted  (1  :  10)  with  saline 
solution,  and  mixed  with  the  slightly  turbid  test-fluid. 
If  the  reaction  is  positive,  the  mixture  becomes  clear, 
a  slight  precipitate  falling  to  the  bottom.  Ten  to  four- 
teen hours  are  allowed  for  the  reaction  to  take  place. 

The  value  of  this  ("  Picker's  diagnostic  ")  as  a  test  is 
confirmed  by  Meyer,2  Ehrsam,3  Sadler,4  and  others.  It  is, 
however,  not  so  delicate  as  Widal's  test  performed  in  the 
ordinary  way.5  If  further  experience  prove  favourable, 
the  discovery  should  afford  a  useful  means  of  applying  the 
test,  as  the  dangers  inseparable  from  living  organisms  and 
the  trouble  of  preparing  fresh  cultures  will  be  avoided. 
The  preparation  is  said  to  keep  well  for  at  least  nine 
months. 

Value  of  Widal's  reaction. — It  was  at  first  hoped 

that  in  Widal's  reaction  we  possessed  a  certain  test  for 
the  existence  of  enteric  fever,  but  we  now  know  that  this 
is  not  the  case.  On  the  one  hand,  a  certain  number  of 
undoubted  cases  of  enteric  fever  fail  to  give  the  reaction 
at  all.  Fatal  cases  are  from  time  to  time  encountered 
which  never  show  any  power  of  agglutination,  but  which 

1  Berlin,  Jclin.  JJ'och.,  1903,  p.  1021. 
-  Ibid.,  1904,  p.  16G. 

3  Munch,  med.  Woch.,  1904,  p.  662. 

4  Berlin,  klin.  JToch.,  1905,  No.  10. 

8  Guttler,  ibirl.,  1904,  Nos.  51,  52  ;  Selter,  MUncti.  mcd.  WocJt.,  190'), 
No.  3. 


GROUP    AGGLUTINATION  81 

present  post  mortem  the  characteristic  lesions  of  the  disease. 
On  the  other  hand,  cases  which  are  not  enteric — e.g. 
paratyphoid  fever — may  exhibit  a  comparatively  high 
agglutinative  power  (see  also  p.  231). 

Other  diseases. — The  serum  of  patients  suffering  from 
other  diseases  may  possess  towards  the  corresponding 
bacteria  as  high  an  agglutinative  power  as  that  found 
in  enteric  fever,  or  even  higher  degrees.  Thus,  in 
Mediterranean  fever  it  is  quite  usual  for  the  serum 
of  patients  to  clump  the  micrococcus  in  dilutions  of  1  :  250, 
or  even  1  :  1,000,  though  here,  too,  a  dilution  of  1  :  50 
is  recommended  as  a  good  practical  working  strength  for 
diagnosis.  The  serum  of  dysentery  patients  may  clump 
Shiga's  bacilli  in  a  dilution  of  even  1  :  1,000  in  some 
instances.  Posselt  and  Sagasser  *  consider  that  a  dilution 
of  1  :  50,  recommended  by  Shiga,  is  here  not  sufficient  to 
secure  an  accurate  diagnosis.  The  serum  of  a  guineapig 
artificially  immunized  against  colon  bacilli  may  react  with 
these  organisms  in  a  dilution  of  1  :  25,000,  while  that 
of  a  typhoid-immunized  horse  may  possess  nearly  equal 
strength. 

Group  agglutination. — The  observers  just  quoted 
show  that  while  a  serum  may  normally  possess  a  power 
of  agglutinating  several  kinds  of  bacteria,  the  process  of 
immunizing  the  animal  against  one  kind  of  organism  will 
raise  the  agglutinative  power  against  the  others,  though 
not  in  equal  degree.  Thus  the  serum  of  a  patient  suffer- 
ing from  dysentery  may  possess  an  agglutinative  power 
for  B.  dysenteries  of  1  :  300,  while  it  may  react  with 
B.  typhosus  at  1  :  75,  with  B.  coli  at  1  :  30,  and  V.  cholerce 
at  1  :  35.  If  examination  were  only  made  for  its  reaction 
with  typhoid  bacilli,  an  error  of  diagnosis  might  easily 
result.  They  therefore  hold  that  it  is  necessary,  before 
accepting  a  reaction  as  positive,  to  test  the  agglutinating 
power  against  several  organisms.  It  need  hardly  be 
pointed  out  that,  if  such  be  the  case,  it  adds  considerably 

1  Op.  cit.  (.wp.  15). 
o 


82         SERUMS,   VACCINES,    AND    TOXINS 

to  the  difficulty  of  making  the  test,  and  thereby  detracts 
greatly  from  its  value  for  everyday  use. 

Persistence  Of  reaction. — The  agglutinative  power  re- 
mains present  in  the  serum  long  after  the  infection  which 
led  to  its  appearance  has  subsided.  Hence  not  only  do 
convalescents  from,  for  example,  enteric  fever  react  to 
Widal's  test,  but  also  persons  who  have  suffered  from  the 
disease  in  previous  years.  How  long  the  property  remains 
is  not  known  for  certain  ;  probably  it  varies  in  different 
individuals,  and  perhaps  according  to  the  severity  of  the 
attack.  In  the  case  of  enteric  fever  it  has  been  proved 
to  persist  for  over  eight  years  (French  and  Louisson), 
and  after  dysentery  it  has  been  found  to  last  for  at  least 
a  year  in  some  cases  (Kruse).  It  is  suggested  that  the 
duration  of  agglutinative  power  corresponds  with  that  of 
immunity  to  the  disease,  but  this  cannot  be  considered 
proved  as  yet. 

A  drawback  to  the  use  of  the  test  as  a  means  of  diagnosis 
lies  in  the  fact  that  it  does  not  appear  quite  at  the  begin- 
ning of  the  illness,  at  which  time  it  is  most  needed  as  an 
aid  to  diagnosis.  Thus,  in  enteric  fever  it  cannot  be  relied 
upon  to  appear  before  the  second  week  of  the  disease ;  in 
plague  it  may  be  absent  until  convalescence.  In  a  person 
who  has  been  inoculated  against  typhoid  fever  the  serum 
becomes  agglutinative,  and  Widal's  reaction  as  applied  to  a 
chance  sample  is  therefore  misleading  if  employed  for  the 
diagnosis  of  obscure  febrile  conditions.  In  such  cases  a 
series  of  observations  must  be  carried  out,  and  the  extreme 
limit  of  agglutination  determined  on  each  of  several 
successive  days.  In  actual  typhoid  infection  the  limit 
will  vary,  but  if  the  reaction  be  due  to  prophylactic 
inoculation  the  agglutination  will  remain  to  all  intents  and 
purposes  steady.  In  dysentery  the  reaction  is  often  want- 
ing in  mild  cases,  according  to  Shiga.  This  author  holds 
that  the  agglutinative  power  in  any  case  bears  a  direct 
proportion  to  the  severity  of  the  infection — a  contention 
that  will  not  hold  good  in  all  cases,  for  a  very  mild  case  of 


OPSONIC   DIAGNOSIS  83 

Mediterranean  fever  seen  by  the  authors  exhibited  a  com- 
plete reaction  when  tested  against  M.  melitensis  in  a  dilution 
of  1  :  500,000,  and  fatal  cases  of  enteric  frequently  fail  to 
elaborate  any  demonstrable  quantity  of  agglutinin. 

DIAGNOSIS  BY  OPSONIC  ESTIMATION 
The  estimation  of  the  opsonic  index  may  be  of  con- 
siderable assistance  in  the  diagnosis  of  obscure  conditions, 
for  an  index  well  above  3  "2  to  any  given  organism  points 
in  no  uncertain  manner  to  infection  by  that  particular 
bacterium.  Moreover,  when,  for  example,  tuberculosis  is 
suspected  and  the  index  at  the  first  estimation  is  within  the 
normal  range  (e.g.  1-2  and  0-8),  a  series  of  observations  at 
frequent  intervals  will  usually  reveal  the  characteristic- 
movements  (see  p.  70)  of  the  patient's  tuberculo-opsonic 
index,  if  the  condition  is  actually  due  to  the  B.  tubercu- 
losis ;  while,  if  it  is  due  to  some  other  cause,  the  index 
will  remain  practically  steady,  or,  at  any  rate,  its  curve 
will  not  show  marked  excursions  from  the  normal  line. 
Occasionally,  however,  it  may  be  necessary  to  extend  the 
observations  of  the  opsonic  index  over  a  considerable  period 
of  time  before  the  resulting  curve  exhibits  characteristic 
features. 

In  order  to  obviate  the  delay  involved  by  watching  the 
natural  movements  of  the  opsonin  curve,  the  metabolic 
products  of  the  tubercle  bacillus,  in  the  form  either  of  an 
auto-inoculation  or  of  tuberculin  (T.R.),  may  be  utilized. 
Thus,  supposing  that  the  case  is  one  of  suspected  tuberculous 
disease  of  the  knee-joint,  or  of  the  kidney,  exercise  of  the 
affected  joint,  either  by  passive  manipulation  or  by  its  use  in 
active  movement  in  the  one  case,  or  palpation  and  massage 
of  the  affected  kidney  in  the  other,  will  lead  to  the  discharge 
of  tubercle  bacilli  or  of  their  products  into  the  circulation, 
and  will  produce  all  the  phenomena  described  as  following 
the  subcutaneous  injection  of  a  suitable  vaccine — in  this 
case  tuberculin — i.e.  negative  phase,  positive  phase,  and  so 
on,  and  will  so  confirm  the  diagnosis.  If,  on  the  other 


84         SERUMS,    VACCINES,    AND   TOXINS 

hand,  the  affection  is  not  of  a  tuberculous  nature,  no 
appreciable  movement  of  the  tuberculo-opsonic  index  will 
take  place. 

If,  however,  it  is  impossible  or  undesirable  actively  to 
interfere  with  the  actual  focus  of  infection,  a  diagnostic  dose 
of  tuberculin  (e.g.  0*0002  mg.  tuberculin,  T.R.)  may  be 
injected  subcutaneously,  and  its  effect  upon  the  amount  of 
opsonin  present  in  the  blood-stream  noted.  For  this  purpose 
samples  of  blood  should  be  taken  immediately  before,  and 
also  one,  four,  twelve,  twenty-four,  and  forty-eight  hours 
after,  the  injection.  All  these  specimens  may  be  examined 
at  one  and  the  same  time  (using  the  same  batch  of  tubercle 
emulsion  and  of  "washed"  cells),  and  all  compared  with 
the  same  control  "  normal "  serum,  when  estimating  the 
opsonic  content  of  each  blood-sample.  With  a  small  dose 
such  as  this,  in  the  case  of  the  tuberculous  lesion,  the 
immediate  transitory  rise  or  spurious  positive  phase,  the 
negative  phase,  and  the  true  positive  phase  may  be  con- 
fidently anticipated  in  rapid  sequence. 

Method  of  determining  the  opsonin-content  of 
the  blood-serum. — For  this  estimation  it  is  necessary  first 
to  prepare  a  quantity  of  living  human  leucocytes  from  some 
indifferent  source  (either  the  patient  or  some  normal  indi- 
vidual), from  which  the  plasma  has  been  completely  re- 
moved by  receiving  the  blood,  as  it  exudes  from  a  needle- 
puncture,  into  a  weak  (1-5  per  cent.)  solution  of  sodium 
citrate  in  normal  saline,  centrifugalizing  the  mixture 
thoroughly,  pipetting  off  the  citrated  plasma,  adding  normal 
saline  solution  to  the  deposited  mass  of  red  cells  and 
leucocytes,  mixing  thoroughly,  and  again  centrifugalizing. 
A  repetition  of  this  "  washing  "  with  normal  saline  and  the 
subsequent  removal  of  the  supernatant  fluid  leaves  a 
sufficient  quantity  of  leucocytes  and  cells  entirely  freed 
from  the  fluid  (which  possibly  contained  excess  of  opsonin) 
in  which  they  were  originally  suspended. 

Next,  a  small  quantity  of  the  blood  to  be  tested  is 
collected  in  a  small  pipette  and  allowed  to  clot,  and  the 


OPSONIC    ESTIMATIONS  85 

serum  is  separated.  Similarly,  the  serum  from  the  normal 
individual  or  "  control "  is  prepared.  Finally,  a  homogeneous 
suspension  of  the  test-bacterium  is  prepared  by  emulsifying 
some  of  the  bacterial  growth  from  a  young  agar-culture 
in  distilled  water,  and  carefully  centrifugalizing  in  order 
to  throw  down  any  possible  clumps  or  masses  of  micro- 
organisms. By  means  of  a  suitable  measuring  pipette 
— for  example,  a  Pasteur  pipette  furnished  with  an  india- 
rubber  teat,  as  introduced  by  Wright  (Fig.  15) — equal 
quantities  of  washed  cells,  of  bacterial  emulsion,  and  of  the 
patient's  serum  are  taken  up  and  thoroughly  mixed,  and  the 
mixture  incubated  at  body-temperature  for  fifteen  minutes. 
At  the  end  of  this  time,  after  preliminary  manipulations  to 
ensure  that  there  is  thorough  incorporation  of  the  mixture, 


Serum         Bacterial        Washed  cells 
emulsion 

Tig.  1.5. — Measuring  pipette  for  opsonin-estimation. 

blood-films  are  spread  therefrom  on  an  ordinary  glass  slide, 
fixed,  and  stained.  A  second  mixture,  in  which  the  normal 
serum  is  substituted  for  the  patient's  serum,  is  prepared 
and  incubated  in  an  identical  manner.  The  two  slides 
are  examined  microscopically,  and  the  number  of  bacteria 
taken  up  and  ingested  by  the  first  50  consecutive  poly- 
morphonuclear  leucocytes  encountered  in  each  film  is 
noted  (Fig.  16).  The  ratio  between  the  resulting  sums  is 
then  expressed  in  the  form  of  a  fraction,  of  which  the 
total  content  of  the  50  cells  mixed  with  the  patient's 
serum  forms  the  numerator,  and  that  of  those  with  the 
normal  serum  the  denominator.  This  fraction  is,  how- 
ever, usually  expressed  as  a  percentage  of  unity — which 
is  represented  by  the  normal  serum.  Thus,  supposing 
150  bacteria  were  counted  in  50  ceils  of  the  preparation 
made  from  the  patient's  serum,  and  100  in  a  similar  number 
in  the  preparation  from  the  normal  control,  the  index  would 


86         SERUMS,   VACCINES,    AND   TOXINS 

be  represented  by  -'-•>{{  or  1'5.  If,  however,  the  specimens 
chosen  had  given  the  figures  60  and  90  respectively,  the 
fraction  would  have  been  f  $  =  0'66. 

Value  of  opsonic  determinations.— The  accuracy  of 

opsonic  determinations  practised  according  to  Wright's 
method  depends  on  the  postulates  that  all  polymorpho- 
nuclear  leucocytes,  whatever  their  source,  are  equally  active 
in  ingesting  bacteria,  and  that  the  opsonic  power  of  the 
serum  is  constant  in  normal  healthy  persons.  The  former 
supposition  is  contrary  to  what  obtains  in  the  case  of 


Fig.  16. — -Edge  of  blood-film  preparation,  showing  phagocytosis  of 
bacilli  by  polymorphonuclear  leucocytes  in  the  presence  of  serum 
containing  opsonin. 

other  vital  phenomena,  in  all  of  which  differences  are 
found  to  exist  between  individuals ;  and  the  uniformity 
of  leucocytic  action  has  been  questioned  on  experimental 
grounds  by  several  observers  (Ledingham,1  Rosenau,2 
Potter3).  Many  series  of  experiments  have  been  per- 
formed to  elucidate  the  constancy  of  the  opsonic  content 
of  normal  persons.  Bulloch4  found  that  the  tubercular 

1  Jottrn.  Infect.  Dis.,  Hi.  683. 

2  Quoted  by  Dean,   Brit.  Med.   Jottrn.,  1907,  ii.  1409   (with  full 
literature). 

8  Jouni.  Amer.  Med.  Assoc.,  1907,  xlix.,  No.  22. 

4  Lancet,  1905,  i.  160. 


OPSONIC    ESTIMATIONS  87 

opsonic  index  in  healthy  persons  might  vary  between  the 
extremes  of  1'2  and  0'8,  the  majority  of  individuals  being 
practically  equal  (I'O).  Such  a  difference  seems  small  in 
itself,  but  it  is  clear  that  a  considerable  percentage  of  error 
may  be  introduced  thereby  into  individual  calculations. 
Thus,  if  a  normal  serum  with  an  index  of  1  -2  be  taken  as 
the  standard,  the  normal  serum  at  the  other  extreme  of  the 
scale  will  be  found  to  have  an  index  of  0-66  ;  while  con- 
versely, if  the  lower  normal  index  be  taken  for  comparison, 
the  higher  will  show  an  index  of  1 '5.  Both  0-66  and  1*5 
would  be  held  to  be  pathological  and  to  point,  the  former  to 
the  possibility,  and  the  latter  to  a  probability  amounting 
for  practical  purposes  to  a  certainty,  of  tubercular  infection. 

This  difficulty  is,  however,  overcome  in  practice  in  one 
of  two  ways,  either  by  using  as  the  normal  serum  the 
"  pooled "  serum  of  several  normal  individuals,  or  by 
always  taking  the  serum  from  the  same  healthy  individual 
(standardized  from  time  to  time  against  "  pooled  "  serum) 
as  the  normal ;  for  the  index  of  the  normal  serum,  whether 
at  one  limit  or  the  other  of  the  normal  range,  remains 
practically  stationary  from  day  to  day. 

Doubt  has  been  thrown  on  the  accuracy  of  the  ordinary 
method  of  estimating  phagocytic  activity  by  Fitzgerald, 
Whiteman  and  Strangeways,1  who  have  shown  that  dif- 
ferent workers  may  with  the  same  serum  obtain  widely 
divergent  results.  For  example,  the  following  pairs  of 
figures  give  extreme  instances  of  such  divergence,  each 
pair  representing  the  indices  obtained  from  one  specimen 
by  different  observers:  1-70-0-36,  1-92-0-68,  M8-0-31. 
Further,  if,  on  the  same  slide,  successive  series  of  50 
leucocytes  are  counted,  very  diffei'ent  numbers  of  enclosed 
bacilli  are  found.'  Thus,  on  the  same  slide  in  one  instance, 
one  series  of  50  cells  contained  119  bacilli,  and  a  second 
series  of  50  contained  74  only.  In  another  instance  the 
numbers  were  150  and  71.  Even  when  100  cells  were 

1  Bull,  of  the  Committee  for  the  Study  of  Special  Diseases.     Cam- 
bridge, 1907,  i.,  No.  8. 


88         SERUMS,    VACCINES,    AND    TOXINS 

counted  instead  of  50,  the  percentage  difference  amounted 
in  one  instance  to  115.  Hence  these  writers  conclude  that 
for  accuracy  of  observation  not  less  than  1,000  cells  must 
be  counted.  Since  this  would  involve  an  expenditure  of 
time  amounting  to  several  hours  for  each  slide,  it  is  clear 
that,  if  these  writers  are  correct,  accurate  estimations  are 
beyond  the  sphere  of  practical  use.  Even  this  alternative 
is  rejected  by  Greenwood,1  who  considers  that  counting 
1,000  cells  will  not  necessarily  give  greater  accuracy  than 
counting  25. 

Even  if  it  be  admitted  that  accurate  estimations  of  the 
phagocytic  activity  of  a  serum  can  be  made,  it  remains  to 
consider  what  the  value  of  such  an  estimation  is  as  a 
measure  of  a  patient's  degree  of  immunity.  It  is  admitted, 
even  by  Wright  himself,  that  the  opsonins  are  not  the  sole 
means  of  resistance  to  bacteria  ;  there  are  besides  not  only 
the  agglutinins,  bactericidins,  and  antitoxins,  but  also  the 
resistance  of  the  cells  of  the  various  tissues,  which  probably 
plays  a  very  important  part.  Measurement  of  the  opsonic 
power  of  the  serum  therefore  throws  light  on  only  one  factor 
in  immunity.  In  earlier  days  the  agglutinating  power  of 
the  serum  was  used  as  an  index  of  immunity,  \mtil  time 
showed  that  it  was  untrustworthy.  Similarly  it  cannot  be 
accepted  without  more  rigorous  proof  that  the  amount  of 
opsonins  present  is  a  fair  measure  of  the  total  resistance. 
In  many  instances  the  variation  of  the  opsonic  index  does 
not  correspond  with  the  clinical  course  of  a  case,  while  it  is 
known  to  alter  in  response  to  slight  influences  which  cannot 
be  supposed  to  affect  the  general  degree  of  resistance.  Thus, 
Latham  ~  found  that  while  the  opsonic  index  in  tuberculous 
individuals  varied  throughout  the  day  inversely  with  the 
patient's  temperature,  a  slight  degree  of  bodily  exercise  in 
such  a  patient  may  notably  reduce  the  index. 

In  spite  of  these  theoretical  objections,  many  com- 
petent observers  believe  that  the  opsonic  index  is  of 

1  Biometrica.     Cambridge,  1909,  6,  Part  iv. 

2  Proc.  Roy.  Soc.  Med.,  1908,  Med.,  i.  195. 


COMPLEMENT-FIXATION  89 

considerable  value  in  indicating  the  general  trend  of  the 
process  of  immunization,  and  of  even  greater  value  in 
indicating  which  of  several  associated  bacteria  is  the  species 
actually  responsible  for  a  condition  of  disease.  Moreover, 
there  can  be  no  doubt  that  the  study  of  the  phagocytic 
properties  of  the  serum  has  not  only  opened  up  a  most 
interesting  chapter  in  pathology,  but  has  had  at  least  one 
very  important  and  most  beneficial  result,  in  that  it  has 
led  to  a  great  reduction  in  both  the  frequency  and  the  size 
of  the  doses  of  tuberculin  generally  employed  (see  pp.  333, 
335).  The  effects  of  minute  doses  are  now  recognized, 
and  a  great  step  towards  a  rational  use  of  the  remedy  has 
been  taken. 

COMPLEMENT-FIXATION 

The  utilization  of  complement  in  a  bacteriolytic  system 
was  originally  suggested  by  Bordet  and  Gengou  as  an  aid 
to  the  identification  of  bacteria,  or  conversely  for  the 
demonstration  of  specific  antibodies,  in  the  serum  of  immu- 
nized animals.  It  was  afterwards  employed  in  the  clinical 
diagnosis  of  bacterial  infections,  and  at  present  finds  its  chief 
application  in  the  diagnosis  of  syphilis  under  the  name  of 
Wassermann's  reaction  (p.  408).  The  test  depends  upon  the 
fact  that  the  same  complement  is  capable  of  entering  into 
combination  with  more  than  one  "  couple"  containing  antigen 
and  its  specific  copula ;  but  complement  thus  added  to  one 
such  "  couple  "  is  used  up  or  fixed,  and  is  therefore  unable  to 
complete  a  second  "  couple  " — say  hsemoly  sin-cry  throcyte,  if 
such  is  subsequently  added  to  the  mixture — and  hsemolysis 
fails  to  take  place.  If,  on  the  other  hand,  specific  copula 
is  absent  from  the  serum  employed  in  the  first  mixture,  the 
complement  remains  free  to  enter  into  combination  with 
the  hsemolysin-e'rythrocyte  couple — and  hsemolysis  takes 
place. 

In  the  diagnosis  of  bacterial  infections  an  emulsion  of 
the  bacterium  suspected  to  be  the  cause  of  the  disease 
serves  as  the  antigen,  and  the  patient's  serum  is  added  on 
the  assumption  that  it  contains  the  specific  copula ;  to 


90         SERUMS,    VACCINES,    AND    TOXINS 

these  two  reagents  serum  containing  complement  is  added, 
and  the  mixture  incubated  for  an  hour  at  body  tempera- 
ture. A  "couple"  consisting  of  mammalian  red  blood- 
t-clls  and  the  corresponding  htemolysin  is  then  added,  and 
the  incubation  repeated,  when  the  presence  or  absence  of 
haemolysis  serves  to  indicate  the  absence  or  presence  of 
the  specific  copula  in  the  patient's  serum.  The  test  as 
applied  to  the  diagnosis  of  syphilis  is  discussed  further 
in  Chapter  XXI. 

DIAGNOSIS  BY  PRECIPITIN  REACTION 

Wassermann-Uhlenhuth  test  for  blood.—  Tchis- 

towitsch1  injected  rabbits  with  the  serum  of  horses,  and 
found  that  the  rabbits'  serum  as  a  result  of  the  injections 
acquired  the  power  of  precipitating  part  of  the  albumin  of 
the  horse-serum  when  mixed  with  it.  Other  observers 
amplified  these  results,  and  in  consequence  Wasserinann 
proposed  to  use  serum  from  animals  previously  injected 
with  human  serum  to  distinguish  human  from  other  blood. 
Uhlenhuth  2  tested  nineteen  kinds  of  blood,  and  found  that 
with  such  a  serum  human  blood  alone  gave  the  reaction. 
Stern,3  however,  showed  that  monkey's  blood  gave  a  reaction 
similar  to  that  produced  by  human  blood. 

In  order  to  prepare  the  antiserum  a  rabbit  is  first 
injected  with  sterile  freshly  defibrinated  blood,  or  prefer- 
ably with  sterile  serum,  at  intervals  of  four  or  five 
days  for  a  period  of  two  or  three  weeks.  The  animal  is 
bled  from  a  vein,  and,  when  the  clot  has  separated,  the 
serum  is  pipetted  off  and  stored  in  a  cool  place. 

In  performing  the  test  the  suspected  blood  is  mixed  with 
a  small  quantity  of  normal  saline  solution  and  filtered :  the 
filtrate  is  divided  between  two  test-tubes,  to  one  of  which  is 
added  twice  the  volume  of  antiserum.  In  another  tube 
is  placed  blood  from  some  other  mammal,  together  with 

1  Ann.  de  Hmt.  Pasteur,  1&»9.  xiii.  40f>. 

2  Berl.  klin.  Wocli.,  1901,  p.  187. 
3Deut.  mcd.  ll'ocJt.,  1901,  p.  l:!.".. 


TOXINS   IN   DIAGNOSIS  91 

antiserum;  and  in  a  fourth  tube  antiserum  mixed  with 
normal  saline  solution.  All  four  tubes  are  incubated  at 
37 °C.  for  one  hour,  then  allowed  to  stand  at  room-tempera- 
ture for  four  hours.  If  the  suspected  blood  is  of  human 
origin  the  first  tube  alone  will  show  evidence  of  precipita- 
tion, the  remaining  three  control  tubes  being  perfectly 
clear.  The  test  is  active  even  in  extreme  dilution — Stern 
quotes  a  positive  reaction  with  blood  diluted  50,000  times. 

TOXINS  AS  MEANS  OF  DIAGNOSIS 
In  some  diseases  the  injection  into  the  affected  animal  or 
patient  of  the  toxins  of  the  bacillus  causing  the  condition 
produces  a  febrile  reaction,  and  use  has  been  made  of  this 
as  a  means  of  diagnosis  in  the  case  of  glanders  and 
tuberculosis.  The  preparation  used  for  the  diagnosis  of 
the  former  disease  is  known  as  "malle'in,"  and  is  much 
used  in  veterinary  practice  to  discover  the  existence  of  the 
disease  in  horses,  in  which  it  is  often  very  latent.  Tuber- 
culin is  similarly  used  on  cattle  to  reveal  the  existence 
of  tuberculosis,  and  has  also  bee  a  employed  in  human 
patients,  though  it  has  not  come  into  general  use,  partly 
owing  to  the  disagreeable  nature  of  the  effects  produced,  and 
to  a  real  or  supposed  risk  of  doing  harm  to  the  sufferer  j 
partly  from  the  existence  of  other  means  of  diagnosis,  such 
as  physical  examination,  and  the  search  for  bacilli  in  the 
expectoration.  It  is,  however,  used  in  the  percutaneous, 
the  cutaneous,  and  the  ophthalmic  reactions  (see  p.  307), 
and  in  suitable  instances  by  subcutaneous  injection 

PHYSICO-CHEMICAL  METHODS 

Brief  allusion  may  be  made  to  certain  methods  of 
diagnosis  wjiich  depend  on  alterations  in  the  physical  and 
chemical  qualities  of  blood-serum  in  special  diseases,  or 
in  relation  to  the  reactions  of  immunity.  For  details  the 
original  papers  should  be  consulted. 

The  combination  of  antigen  and  antibody,  with  absorp- 
tion of  complement,  is  said  to  be  accompanied  by  an 


92         SERUMS,    VACCINES,    AND    TOXINS 

alteration  in  the  surface-tension  of  the  fluid  in  which  the 
reaction  takes  place.  Observations  were  made  on  the 
phenomenon  by  Weichardt  and  by  Ascoli,  and  the  latter 
devised  a  special  test  known  as  the  meiostagmin  reaction,1 
in  which  the  number  of  drops  formed  by  a  known  quantity 
of  a  mixtui'e  of  serum,  antigen,  and  antibody  is  counted, 
and  compared  with  that  formed  by  a  similar  mixture  made 
with  normal  serum  as  a  control.  The  test  is  positive  if 
the  drops  are  smaller,  and  are  therefore  more  numerous, 
with  the  serum  to  be  tested.  The  instrument  used  for 
counting  them  is  Traube's  stalagmometer. 

Allied  to  this  reaction  is  the  so-called  epiphanin  '-'  re- 
action of  Weichardt,  which  depends  on  an  alteration  in 
the  reaction  to  phenolphthalein  of  an  exactly  neutralized 
mixture  of  barium  hydrate  and  sulphuric  acid  in  the 
presence  of  an  antigen-antibody  combination.  For  the 
performance  of  the  test  Ol  c.c.  of  a  1  :  10  dilution  of 
serum  in  normal  saline  solution  is  mixed  with  O'l  c.c. 
alcoholic  extract  of  syphilitic  foetal  liver  (also  diluted 
1  :  10).  One  cubic  centimetre  of  decinormal  sulphuric  acid 
is  added,  and  then  an  amount  of  barium  hydrate  solution 
which  has  been  previously  found  to  neutralize  exactly  the 
above  amount  of  the  dilute  acid.  On  adding  a  drop  of 
alcoholic  solution  of  phenolphthalein,  a  red  colour  appears 
if  the  serum  tested  is  syphilitic  :  a  control  test  with  normal 
serum  remains  colourless.  The  test  is  said  to  give  good 
results  as  a  diagnostic  agent  in  syphilis  (Seiffert),3  but  it 
has  not  come  into  general  use. 

Alterations  in  the  quantities  of  globulin  present  in  the 
serum  are  the  basis  of  the  reactions  named  after  Forges 
and  Hermann  and  Perutz.  To  elicit  Forges'  reaction  4 

1  From  nfiov,  smaller,  and  arafa,  I  drip — i.e.  smaller  drops.  See 
Ascoli,  Miinch.  med.  Woch.,  1910,  p.  62. 

-  (irHpdvfia,  surface.  Weichardt,  Zeitschr.  /.  Immttnitat»fr>rsc/i., 
1910,  Orig.,  vi.  842. 

8  Deut.  med.  Woch.,  1910,  p.  2333. 

4  De  la  Motte,  ibid.,  1910,  p.  1561. 


PHYSICO-CHEMICAL   TESTS  93 

0'2  c.c.  of  clear  sterile  inactivated  serum  is  mixed  with  the 
same  quantity  of  a  1  per  cent,  solution  of  sodium  glyco- 
cholate,  and  the  mixture  is  allowed  to  stand  at  room-tem- 
perature for  [sixteen  to  twenty  hours.  At  the  end  of  that 
time,  if  the  test  is  positive,  definite  floccules  have  formed  in 
the  mixture,  and  tend  to  rise  to  the  surface  of  the  fluid.  The 
method  of  performing  the  Hermann-PerutZ1  test  is  very 
similar. 

In  Rivalta's  reaction2  two  solutions  are  prepared, 
the  first  consisting  of  a  drop  of  saturated  solution  of  sodium 
carbonate  in  100  c.c.  of  distilled  water,  and  the  second  of 
2  drops  of  glacial  acetic  acid  in  100  c.c.  of  water.  The 
blood  or  serum  to  be  tested  is  diluted  1  :  100  with  the  first 
fluid,  and  then  a  drop  of  this  mixture  is  taken  up  on  a  glass 
rod  and  allowed  to  fall  into  some  of  the  second  fluid  in  a 
beaker.  If  the  test  is  positive,  a  white  ring  appears  where 
the  drop  falls,  probably  consisting  of  globulin. 

Klausner's  reaction,3  consisting  in  the  formation  of  a 
cloudy  precipitate  on  adding  distilled  water  to  syphilitic 
serum,  is  said  to  depend  on  the  presence  of  a  lipoid  body. 

1  Med.  Klinik,  1911,  No.  2. 

-  Policlinico,  1905,  vol.  xii.  ;  also  1910,  Sez.  Prat.,  Nos.  22  and  23. 
Cf.  Gironi,  Milt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1913,  xxv.  229. 
3  Biochemisch.  Zeitschr.,  1912,  xlvii.  36. 


CHAPTER     V 
DIPHTHERIA 

Nature  Of  diphtheria. — Diphtheria,  derived  from  the 
Greek  word  Suftdepa,  a  skin  or  piece  of  leather,  was  a 
term  originally  applied  to  cases  of  sore-throat  characterized 
by  the  presence  of  "  false  membrane."  When  the  condition 
came  to  be  examined  bacteriologically,  it  was  found  that  the 
great  majority  of  these  cases  are  associated  with  the  growth 
of  a  particular  bacillus  (B.  diphtheria^).  It  was  therefore 
assumed  that  all  cases  of  the  disease  were  due  to  this 
organism,  and  it  became  necessary  from  the  public-health 
point  of  view  to  diagnose  diphtheria  solely  on  bacteriological 
findings.  A  case  of  sore  throat  in  which  the  bacillus  is 
found  is  now  called  "  diphtheria,"  apart  from  the  presence 
or  absence  of  the  characteristic  clinical  symptoms  (mem- 
brane-formation),1 while  cases  of  membranous  sore-throat 
in  which  pneumococci,  pneumobacilli,  or  streptococci  are 
alone  present,  and  in  which  no  diphtheria  bacilli  can  be 
detected,  are  not  regarded  as  instances  of  the  disease.  The 
practical  result  is  to  change  the  connotation  of  the  term 
diphtheria  from  that  of  "  membranous  sore-throat "  to  that 
of  "sore-throat  due  to  B.  diphtherice."  A  recognition  of 
these  facts  will  be  seen  to  be  of  importance  when  the 
evidence  for  the  value  of  antitoxic  serum  is  discussed. 

Causal  Organism. — The  Bacillus  diphtheria'  was  first 
discovered  by  Klebs  in  the  year  1883,  and  was  cultivated 

1  At  the  hospitals  of  the  Metropolitan  Asylums  Board  cases  are 
now  classified  as  "diphtheria"  and  "bacteriological  diphtheria,"  the 
latter,  in  which  there  are  no  clinical  signs  of  diphtheria,  being  a 
non-fatal  condition,  although,  as  "  carriers,"  individuals  harbouring 
diphtheria  bacilli  are  a  source  of  danger  to  the  community. 

94 


DIPHTHERIA   BACILLUS  95 

by  LoetHer  in  the  following  year ;  hence  it  is  generally 
known  as  the  Klebs  Loeffler  bacillus.  It  belongs  to  a  group 
of  organisms  the  exact  relations  between  the  members  of 
which  are  not  definitely  decided.  The  most  closely  allied 
form  is  the  so-called  pseudo-diphtheria  bacillus,  which 
resembles  the  pathogenic  organism,  but  is  not  virulent  for 
animals.  Its  relation  to  cases  of  sore-throat  in  human 
beings  is  still  undecided.  Culturally  it  is  quite  distinct  from 
the  Klebs-Loeffler  bacillus  ;  moreover,  it  is  said  not  to  be 
agglutinated  by  the  serum  of  animals  rendered  immune 
against  the  Klebs-Loeffler  bacillus — strong  evidence  of  the 
diversity  of  the  two  organisms.  Another  closely  allied,  if 
not  identical,  organism  is  the  Bacillus  xerosis,  which  is  met 
with  in  the  conjunctival  sac  and  was  at  one  time  supposed 
to  be  causally  associated  with  the  affection  of  the  eye 
known  as  xerosis  conjunctivas ;  it  is  also  of  common  occur- 
rence in  the  discharge  of  otitis  media,  in  association  with  the 
pathogenic  organisms  responsible  for  the  suppuration,  and 
is  a  very  common  saprophyte  of  the  external  genitals. 
Diphtheroid  bacilli  have  also  been  found  in  the  disease 
called  noma  or  cancrum  oris. 

Occurrence  in  the  body. — The  Klebs-Loeffler  bacillus 
is  met  with  not  only  in  cases  of  diphtheria,  but  also  in 
chronic  nasal  discharges.  It  may  likewise  be  found  in  a 
virulent  condition  in  the  throats  of  healthy  persons,  and 
may  gain  a  footing  on  any  open  wound  and  there  give  rise 
to  the  formation  of  false  membrane. 

In  cases  of  membranous  sore-throat  in  which  the 
diphtheria  bacillus  is  found,  it  may  occur  either  in  almost 
pure  culture  or  mixed  with  other  organisms,  especially 
streptococci.  These  mixed  cases  are  generally  more  severe, 
and  the  prognosis  is  worse  than  in  simple  diphtherial 
infection.  As  in  the  throat,  so  also  on  wounded  surfaces, 
other  bacteria,  such  as  streptococci  and  the  pneumobacillus 
of  Friedlander,  may  form  false  membrane,  so  that  every 
such  formation  is  not  diphtheritic  in  the  bacteriological 
sense  of  the  word,  i.e.  caused  by  the  B.  diphtheria. 


9G         SERUMS,    VACCINES,    AND    TOXINS 

In  cases  of  diphtheria  the  bacilli  remain  for  the  most 
part  confined  to  the  false  membrane  in  the  fauces  ;  no 
general  infection  of  the  blood  takes  place  as  a  rule,  though 
in  severe  cases  some  of  the  bacilli  may  gain  access  to  the 
blood-stream  ;  apparently,  however,  they  do  not  multiply 
therein,  and  consequently  do  not  give  rise  to  a  true 
septicaemia.  By  direct  extension,  however,  as  can  frequently 
be  demonstrated  at  the  necropsy,  the  diphtheria  bacillus 
may  invade  the  bronchi  and  so  give  rise  to  a  membranous 
broncho-pneumonia ;  and  in  one  instance  the  writers 
have  seen  the  extension  of  the  membrane  into  the 
stomach. 

Diphtheria  bacilli  manufacture  a  substance,  probably  in 
the  nature  of  a  ferment,  which  is  absorbed  and  carried  by 
the  blood  and  lymph  all  over  the  body.  This  ferment,  by 
its  action  on  the  tissues,  gives  rise  to  other  poisonous 
materials  or  secondary  toxins.  The  bodies  of  the  bacilli 
themselves  are  not  so  poisonous  as  their  soluble  products  ; 
thus  Kossel1  showed  that  if  the  actual  bacteria  were 
washed  free  from  the  poison  and  then  killed,  the  dead 
bodies  had  very  little  toxic  influence  when  injected  into 
animals. 

Toxins  of  diphtheria. — The  nature  of  the  poisons 
manufactured  by  the  diphtheria  bacillus  was  studied  very 
early  in  the  history  of  modern  bacteriology,  since  the 
organisms  form  soluble  toxins  which  can  be  readily 
obtained  in  culture-media. 

Roux  and  Yersin2  were  the  first  who  discovered  the 
presence  of  diphtherial  toxins  in  peptone-broth  cultures  of 
the  bacilli  (1888,  1889).  Solutions  of  the  poisons  may  be 
prepared  by  growing  the  organisms  in  broth  for  periods 
of  two  to  four  weeks,  and  then  either  passing  the  fluid 
through  a  porcelain  filter,  so  as  to  strain  off  the  bacilli,  or 
adding  a  germicide  of  some  sort  to  it,  so  as  to  kill  them. 
Toluol  has  been  used  for  the  latter  purpose  by  Ehrlich  and 

1  Centralbl.  f.  Sakt.,  I.,  1896,  xix.  977. 

2  Ann.  df  VInst.  Pasteur,  1888-9. 


TOXINS    OF   DIPHTHERIA  97 

Wassermann.1  The  fluid  is  well  shaken  up  with  this 
substance,  which  separates,  on  standing,  into  a  layer 
floating  on  the  surface  of  the  broth.  In  this  condition  the 
preparation  can  be  kept  indefinitely,  as  the  toluol  prevents 
any  decomposition  taking  place.  The  bodies  of  the  bacilli 
sink  to  the  bottom  of  the  flask.  A  special  method  of 
growing  the  bacteria  was  devised  by  Aronson,2  in  which 
they  are  induced  to  form  a  scum  or  coat  on  the  surface  of 
the  broth  ;  thus  treated,  they  produce  a  much  stronger 
toxin  than  when  they  are  cultivated  in  the  ordinary  way, 
diffused  through  the  fluid  medium. 

The  effects  of  the  poison  are  seen  equally  well  whether 
the  living  bacilli  or  the  prepared  toxins  are  used  for 
experimental  injection.  A  guineapig  which  has  received  a 
dose  of  the  organisms  subcutaneously  presents  first  at  the 
site  of  injection  an  cedematous  swelling;  this  is  followed 
by  enlargement  of  the  neighbouring  lymphatic  glands.  The 
animal  appears  to  become  weaker  and  weaker,  and  dies,  if  a 
moderately  strong  dose  has  been  given,  in  the  space  of  about 
four  days.  An  examination  of  the  body  then  shows  the 
existence  of  oedema  and  haemorrhage  at  the  site  of  injection, 
and  serous  effusion  into  the  cavities  of  the  pleurae,  peri- 
cardium, and  peritoneum.  The  bacilli  are  not  found  to  have 
become  generalized  throughout  the  body.  Very  large  doses 
of  toxins  or  very  virulent  bacilli  may  produce  death  in 
twenty-four  hours. 

If  weaker  doses  of  poison  are  administered,  insufficient 
to  cause  death,  the  most  marked  phenomenon  may  be  the 
local  swelling ;  and  if  life  is  prolonged  for  as  much  as  a 
fortnight,  paralytic  symptoms  may  supervene,  and  the 
guineapigs  die  of  asthenia.  There  is  reason  to  believe  that 
at  least  three  separate  poisons  are  manufactured  by  the 
Klebs-Loeffler  bacillus  :  one,  which  is  the  most  important, 
causes  deatli  by  a  general  neuro-muscular  intoxication ;  a 
second  produces  the  local  redema  at  the  point  of  inoculation, 

1  Zeitsehr.f.  Hygiene,  Bd.  xix.,  1893. 
-  Berlin,  klin.  Woch.,  1894,  p.  426. 


98         SERUMS,    VACCINES,    AND    TOXINS 

which  may  actually  go  on  to  necrosis  of  the  superficial 
tissues ;  and  the  third  is  responsible  for  the  paralysis  which 
sometimes  occurs  as  a  sequel. 

As  to  the  exact  chemical  composition  of  the  toxins, 
little  is  definitely  known.  Roux  and  Yersiii  considered  that 
the  main  poison  was  of  the  nature  of  a  ferment ;  they  found 
that  the  toxic  substance  which  they  succeeded  in  isolating 
did  not  act  in  the  presence  of  acid.  Sidney  Martin  was  also 
led  to  believe  that  the  primary  poison  is  a  ferment.  He 
isolated  from  the  tissues  of  animals  dead  of  the  disease,  as 
well  as  from  the  culture  media  in  which  the  organisms 
had  been  grown,  a  series  of  albumoses  (proto-,  deutero-, 
and  hetero-alburnose),  as  well  as  an  organic  acid.  He 
considered  that  the  albumoses  were  formed  in  the  tissues, 
especially  in  the  spleen,  not  in  the  false  membrane.  In 
this  latter  the  ferment  was  generated,  and  thence  it  was 
absorbed  by  the  blood-vessels.  Brieger  and  Bor1  grew  the 
bacilli  in  dialysed  urine,  a  non-albuminous  fluid,  and  precipi- 
tated the  toxin  by  means  of  zinc  chloride.  The  material 
thus  prepared  was  non-albuminous  ;  it  was  very  sensitive  to 
oxidizing  agents,  but  resistant  to  reducing  substances.  It 
was  highly  toxic  to  animals,  and  the  injection  of  it  in 
small  quantities  produced  immunizing  substances  in  their 
serum.  These  observers  found  that  the  bodies  of  the 
bacteria  contained  a  substance  which  was  capable  of  caus- 
ing necrosis  of  living  tissues,  and  which  did  not  give  rise  to 
antitoxin  in  the  serum.  In  this  respect  they  are  at  issue 
with  Kossel,2  who  found  the  bodies  of  the  bacteria  only 
slightly  toxic. 

DIPHTHERIAL    ANTITOXIN 

Manufacture  of  antitoxin.— For  the  production  of 

antitoxin  it  is  necessary  to  prepare  a  toxin  of  the  highest 
possible  virulence.  Certain  strains  of  the  bacillus  appear 
to  be  specially  adapted  to  form  toxins  in  artificial  media, 

1  Deut.  mrd.    ll'ocl.,  1896,  p.  784. 

2  Loc.  cit.f  p.  96. 


DIPHTHERIAL   ANTITOXIN  99 

adopting  the  peculiar  form  of  growth  already  described 
(formation  of  a  pellicle  on  the  surface  of  the  nutrient  fluid), 
which  is  found  to  be  most  advantageous  for  this  purpose. 
When  the  organisms  have  grown  for  about  a  fortnight  on 
the  culture-fluid,  the  latter  is  passed  through  a  porcelain 
filter;  the  bacilli  are  thus  removed,  and  the  filtrate  is  ready 
for  use. 

The  horse  selected  for  the  production  of  antitoxic  serum 
is  submitted  to  a  preliminary  examination  with  mallein  and 
tuberculin  to  ensure  that  it  is  free  from  glanders  and  tuber- 
culosis. If  it  fails  to  react  to  these  tests,  it  receives  an 
injection  of  a  small  quantity  of  the  toxin  l  (^  to  1  c.c.)  sub- 
cutaneously  in  the  loose  tissue  at  the  root  of  the  neck.  The 
injection  is  followed  by  considerable  local  reaction,  causing 
the  appearance  of  a  large  swelling,  while  the  horse  exhibits 
signs  of  fever  and  constitutional  disturbance.  It  is  neces- 
sary to  wait  till  these  symptoms  have  subsided  before 
administering  a  second  injection,  which  may  be  given  on  the 
opposite  side  of  the  neck.  The  doses  are  gradually  inci-eased 
till  as  much  as  an  entire  litre  of  the  toxin  may  be  injected 
for  a  single  dose.  The  febrile  disturbance  produced  by  the 
poison  becomes  less  and  less  as  the  treatment  continues. 
It  appears  to  be  a  good  sign  that  the  horse  should  react 
strongly  at  first,  as  such  animals  seem  to  produce  in  the  end 
a  more  highly  antitoxic  serum.  Some  horses  fail  altogether 
to  form  antitoxin ;  probably  the  receptors  of  their  cells 
have  not  enough  affinity  for  the  toxin,  and  so  the  number 
killed  is  not  sufficient  to  stimulate  reproduction  in  excess. 

The  injection  of  each  dose  of  poison  is  followed  by 
an  immediate  fall  in  the  antitoxic  value  of  the  serum  of 
the  horse,  but  this  rises  again  in  the  course  of  a  day  or 
two  to  a  point  higher  each  time  than  that  at  which  it 
previously  stood.  It  is  important  not  to  give  a  fresh  dose 
of  toxin  till  this  rise  in  antitoxic  power  has  taken  place  ; 
otherwise  the  antitoxin  present  may  actually  be  diminished 
instead  of  increasing.  As  a  rule  the  injections  are  given 
1  I.e.  the  toxic  culture-fluid. 


100       SERUMS,   VACCINES,   AND   TOXINS 

about  once  in  three  to  seven  days.  The  antitoxic  power  of 
the  blood  reaches  its  maximum  in  about  six  months.  A 
horse  will  not  go  on  indefinitely  producing  antitoxin ;  its 
power  in  this  direction  appears  to  become  exhausted  after 
a  time. 

Standardization  of  toxin  and  antitoxin.— As  has 

already  been  pointed  out,  it  is  not  possible  to  weigh  or 
measure  toxins  and  antitoxins  as  we  do  ordinary  drugs, 
and  therefore  their  strength  can  only  be  measured  by  means 
of  physiological  tests,  that  is  to  say,  by  determining  experi- 
mentally the  effects  produced  on  living  animals.  For  the 
purpose  of  standardizing  the  toxins  of  diphtheria,  guinea- 
pigs  are  the  animals  generally  used,  as  it  is  found  that  they 
react  in  a  very  constant  manner  to  the  poison  ;  those  of  the 
same  weight  being  killed  in  approximately  the  same  period 
of  time  by  equal  doses  of  a  given  toxin.  A  unit  dose  of 
toxin  is  that  amount  of  any  preparation  of  diphtherial 
poison  which  will  just  suffice  to  kill  a  guineapig  weighing 
250  grm.  in  a  period  of  four  days.  This  is  also  known  as 
the  "  minimal  lethal  dose  (m.  1.  d.)." 

A  unit  of  antitoxin  is  the  smallest  quantity  which, 
being  mixed  with  100  minimum  lethal  doses1  of  toxin  and 
injected  into  a  guineapig,  prevents  the  appearance  of  any 
toxic  symptoms. 

This  method  of  standardization  is  the  one  inaugurated  by 
Ehrlich.  It  was  necessary  in  the  first  instance  to  establish 
a  toxic  unit,  and  then  to  calculate  from  this  the  antitoxic 
unit.  When  this  had  once  been  done,  however,  it  became 
easier  subsequently  to  calculate  backwards  from  antitoxin  to 
toxin,  since  the  former  is  more  easily  preserved,  not  varying 
in  strength  even  when  kept  for  considerable  periods  of  time. 
A  standard  antitoxin  is  supplied  by  the  Serumprufungs 
Institut  at  Frankfort-on-Main,  and  this  standard  is  now 
universally  adopted. 

1  This  quantity  of  toxin,  sufficient  to  kill  100  guineapigs,  and 
exactly  neutralized  by  one  unit  of  antitoxin,  is  called  by  Ehrlich  the 
LU  dose. 


TOXIN   AND   ANTITOXIN  101 

A  method  of  standardizing  antitoxin,  founded  on  the 
determination  of  the  L-f  dose  (seep.  102),  has  recently  been 
introduced  in  place  of  the  one  described  above.  A  stand- 
ard antitoxin  being  available,  unit  doses  of  it  are  taken  ; 
varying  quantities  of  (any)  toxin  are  added  to  these,  and 
the  mixtures  are  injected  into  guineapigs,  until  the  exact 
mixture  (1  unit  antitoxin  and  x  toxin)  necessary  to  pro- 
duce death  on  the  fourth  day  is  discovered.  This  amount 
(x)  of  the  toxin  is  then  mixed  with  varying  quantities  of 
the  antitoxin  which  is  to  be  standardized,  and  the  quantity 
of  this  latter  which  must  be  added  to  the  above  (x)  amount 
of  toxin,  in  order  that  the  animal  may  be  killed  in  the 
given  time,  is  ascertained.  This  quantity  is  thus  proved 
to  contain  exactly  one  unit  of  antitoxin,  its  action  being 
precisely  equivalent  to  that  of  the  original  standard  unit. 

Interaction  of  toxin  and  antitoxin.—  From  the 

facts  just  recorded  it  has  been  assumed  that  the  relation 
between  given  specimens  of  toxin  and  antitoxin  is  con- 
stant, the  same  quantity  of  the  latter  being  always  re- 
quired to  neutralize  exactly  a  given  amount  of  the  former. 
This  is  practically  true  within  limits.  The  interaction 
between  the  two  substances  therefore  resembles  a  simple 
chemical  combination,  similar  to  that  which  takes  place 
between  an  acid  and  an  alkali.  But  in  the  case  of 
the  substances  which  we  are  considering  certain  curious 
phenomena  have  been  observed,  showing  that  we  are  not 
dealing  with  a  case  of  simple  chemical  combination.  If  we 
take  a  certain  quantity  of  a  simple  acid  and  add  to  it  the 
amount  of  the  alkali  which  exactly  neutralizes  it,  we  have  a 
mixture  corresponding  with  the  mixture  of  one  unit  of  anti- 
toxin with  100  minimal  lethal  doses  of  toxin.  If  to  the 
former  mixture  we  add  any  fresh  quantity  of  the  acid,  it 
will  remain  uncombined  and  capable  of  producing  its  normal 
effects  (combining  with  more  alkali,  etc.).  If,  however,  we 
take  the  mixture  of  toxin  and  antitoxin,  and  add  to  it  one 
minimal  fatal  dose  of  toxin,  we  do  not  find  that  this  addi- 
tional toxin  has  still  its  usual  effect,  viz.  to  kill  a  guinea- 


Ofc"ll£OI 


102       SERUMS,    VACCINES,    AND    TOXINS 

pig  of  250  grm.  in  four  days.  On  the  contrary,  if  the 
mixture  (unit  of  antitoxin  -f  100  minimal  fatal  doses  of 
toxin  -t- 1  extra  minimal  fatal  dose)  is  injected  into  a  guinea- 
pig,  the  animal  recovers  from  the  injection,  only  exhibiting 
a  certain  amount  of  oedema  at  the  point  of  injection.  If 
still  further  quantities  of  toxin  are  added,  it  will  be  found 
that  quite  a  large  number  of  toxic  units  must  be  added 
before  a  point  is  reached  at  which  the  animal  dies  in 
four  days.  This  additional  quantity  is  called  by  Ehrlich 
the  L+  dose. 

We  may  make  the  same  experiment  in  another  manner. 
If  we  take  the  amount  of  toxin  which  is  exactly  neutralized 
by  one  unit  of  antitoxin,  viz.  100  lethal  doses,  add  to  it 
i££  of  a  unit  of  antitoxin,  and  inject  the  mixture  into  a 
guineapig,  the  animal  does  not  die,  but  only  suffers  from 
some  local  oedema.  This  might,  indeed,  have  been  foretold, 
as  there  should  theoretically  be  set  free  only  one-half  of  a 
minimal  lethal  dose  of  poison.  If,  however,  we  proceed 
further  in  the  same  way,  and  add  to  the  same  quantity  of 
toxin  !£§  of  a  unit  of  antitoxin,  we  should  expect  death 
to  occur  on  the  fourth  day,  as  one  lethal  dose  should  now 
be  available.  But  again  only  local  oedema  results.  Pro- 
ceeding in  this  way,  it  is  found  that,  even  if  i£°  of  a  unit 
is  added,  the  mixture  is  still  incapable  of  killing  the  animal 
in  the  stated  time.  When,  however,  the  100  lethal  doses 
of  toxin  are  mixed  with  only  ii?  of  a  unit  of  antitoxin, 
then  one  minimal  lethal  dose  is  set  free  and  the  usual  effect 
is  produced.  It  is  found  at  this  point  that  for  each  ¥^^  of 
a  unit  of  antitoxin  that  is  subtracted,  one  lethal  dose  is 
set  free.  This  continues  till  a  point  is  reached  at  which  we 
have  arrived  at  a  mixture  of  100  m.  1.  d.  of  toxin  with  /;,",, 
of  a  unit  of  antitoxin  ;  this  is  capable  of  killing  100  guinea- 
pigs.  Any  further  diminution  of  antitoxin  is  without  effect. 

Put  in  other  words,  it  appears  that  it  is  possible  to  add 
to  100  lethal  doses  of  poison  as  much  as  one-quarter  of  the 
total  amount  of  antitoxin  which  will  exactly  neutralize 

them,  without  decreasing  the  available  toxic  capacity.    If  a 
:  I  J 


TOXIN   AND   ANTITOXIN 


103 


further  half-unit  of  antitoxin  is  added,  the  whole  of  the 
poison  is  neutralized. 

The  explanation  of  these  phenomena  given  by  Ehrlich 
is  that  the  crude  poison,  if  it  may  so  be  called — the  culture- 
medium  in  which  the  bacteria  have  grown — contains 
several  different  substances,  all  of  which  have  the  power  of 
combining  with  antitoxin.  They  have,  however,  different 
degrees  of  affinity  for  the  latter.  The  body  which  has  the 


Toxone 


Toxin 


Prototoxoid 


(3) 


(i) 


Toxins.         Antitoxin. 

Fig.  17. — Diagram  illustrating  the  process  of  saturation  of 
diphtherial  toxin  with  antitoxin. 

greatest  avidity  for  antitoxin  is  called  "prototoxoid."1 
The  main  toxin,  which  causes  the  death  of  the  guineapig, 
occupies  an  intermediate  place  in  point  of  affinity,  while  a 
third  substance,  called  "  toxone,"  has  the  least  affinity  of 
all.  This  last  appears  to  be  the  body  which  is  responsible  for 
the  local  O3dema'  seen  at  the  point  of  injection  of  crude 
diphtherial  toxins. 

The  accompanying  diagram  (Fig.  17)  will  perhaps  serve 

1  It  has  been  suggested  that  toxoids  consist  of  free  "haptophore" 
molecules  of  toxin  which  have  lost  their  "toxophore"  element 
(see  p.  25). 


104       SERUMS,    VACCINES,    AND    TOXINS 

to  make  a  little  clearer  what  happens  on  gradually  adding 
antitoxin  to  toxin.  The  tube  on  the  left  shows  the  rela- 
tive proportions  of  each  substance  present  in  a  specimen 
of  crude  poison.  If  now  antitoxin  be  added,  filling  up,  as 
it  were,  the  tube  from  the  bottom,  it  will  first  of  all  neu- 
tralize the  prototoxoid,  one-quarter  of  the  whole  antitoxin 
being  thus  occupied.  The  next  two  quarters  will  be  taken 
up  by  the  toxin,  and  the  last  quarter  of  all  by  the  toxone. 
The  first  addition  of  antitoxin  does  not  reduce  the  tox- 
icity  of  the  mixed  poisons,  because  it  merely  neutralizes 
the  prototoxoid,  which  has  no  poisonous  properties.  The 
second  addition  counteracts  the  most  active  poison,  the  true 
toxin ;  while  the  last  addition  prevents  the  local  effects 
which  are  caused  by  the  toxone. 

Again,  if  we  take  a  mixture  in  which  the  toxins  are 
exactly  neutralized  by  antitoxin  (neglecting  for  the  sake  of 
simplicity  the  prototoxoid),  the  addition  of  a  further  unit 
of  toxin  will  tend  to  set  free  an  equivalent  quantity  of 
toxone,  which  has  less  affinity  for  the  antitoxin ;  and  on 
adding  still  further  quantities  of  toxin  a  fatal  amount  will 
not  be  reached  till  all  the  toxone  has  been  set  free  and 
its  proportion  of  the  antitoxin  annexed  by  the  toxin. 

The  following  illustration  of  the  interaction  of  antitoxin 
and  toxin  in  diphtheria,  by  means  of  an  analogous  process 
in  ordinary  chemistry,  is  given  by  Emery.1 

"  You  remember  that  in  estimating  chlorides  by  titration 
with  silver  nitrate  you  add  a  little  chromate  of  potash  to 
the  solution  to  be  tested.  The  silver  has  a  greater  affinity 
for  the  chloride  than  for  the  chromate,  and  you  get  a  white 
precipitate  of  silver  chloride  until  all  the  soluble  chlorides 
have  been  decomposed,  and  then  you  begin  to  get  a  choco- 
late-coloured precipitate  of  silver  chromate.  In  precisely 
the  same  way,  when  you  add  antitoxin  to  diphtheria 
poison,  the  first  portion  added  goes  to  combine  with  the 
prototoxoids,  and  these  must  be  completely  saturated 
before  any  toxin  is  neutralized." 

1  St.  Bartholomew's  Hosp.  Journ.,  Dec.,  1902,  p.  37. 


TOXIN   AND   ANTITOXIN  105 

In  addition  to  the  above  facts,  there  are  certain  pecu- 
liarities about  the  mixture  resulting  from  addition  of 
antitoxin  to  toxin  which  throw  doubt  on  the  explanation 
of  their  interaction  as  a  simple  chemical  combination. 
Thus,  a  mixture  of  toxin  and  antitoxin  may  be  made 
which  is  neutral  for  a  mouse,  but  which  when  injected  into 
a  guineapig  may  cause  toxic  symptoms ;  and  Behriug ' 
found  that  a  mixture  of  1  unit  of  toxin  with  a  correspond- 
ing amount  of  antitoxin,  which  is  neutral  for  a  guineapig, 
is  still  toxic  for  the  ass,  and  that  apes  are  killed  by  two  or 
three  injections  of  a  mixture  of  1  unit  of  toxin  with  40 
units  of  antitoxin.  Again,  if  the  mixture  be  heated  to 
100°  C.,  the  antitoxin  is  destroyed  and  the  toxin  remains 
unneutralized.  Similarly,  if  the  mixture  be  passed  through 
a  porcelain  filter,  the  toxin  passes  through  in  the  filtrate, 
and  the  antitoxin  remains  behind  ;  while  if  the  same  mixture 
be  injected  into  an  animal,  the  toxin  may  be  eliminated  in 
an  active  condition  in  the  urine.  It  seems  difficult  to  explain 
these  phenomena  on  the  basis  of  a  simple  chemical  combina- 
tion. Some  authorities  have  maintained  that  antitoxin 
does  not  act  directly  on  the  toxin,  but  indirectly  through 
the  medium  of  the  living  cell,  which  it  stimulates  in  some 
way  to  resist  the  poison  (Roux,  Biichner).  Danysz2  con- 
siders that  toxin  and  antitoxin  may  combine  in  different 
proportions  to  form  a  series  of  "  compounds,"  somewhat  ana- 
logous to  the  series  of  oxides  of  nitrogen,  N2O,  N300,  N0O3, 
etc. ;  and  Bordet,3  who  also  holds  this  view,  considers  that 
toxone  is  in  reality  a  molecule  of  toxin  incompletely  satu- 
rated with  antitoxin.  The  question  is  a  very  difficult  one 
and  cannot  be  decided  on  the  data  at  present  available.  It 
seems  probable  that  a  definite  chemical  combination  occurs, 
but  that  the  affinity  between  the  two  substances  is  com- 
paratively slight,  so  that  the  combination  only  takes  place 
slowly  and  is  readily  decomposed.  Arrhenins  and  Madsen 

1  Deut.  med.  Woch.,  1913,  p.  873. 

2  Ann.  de  I' List.  Pasteur,  1902,  xvi.  315. 

3  Ibid.,  1903,xvii.  185. 


106       SERUMS,    VACCINES,    AND    TOXINS 

hold  this  view  and  consider  that  the  results  ascribed  by 
Ehrlich  to  the  action  of  toxone  are  really  due  to  the 
presence  of  dissociation-products. 

Von  Calcar 1  states  that  he  was  able  by  fractional 
dialysis  to  separate  the  toxin  from  the  toxone,  thus  proving 
them  to  be  distinct  chemical  bodies,  but  his  methods  and 
results  have  been  called  in  question  by  Homer.2 

In  the  case  of  the  toxin  and  antitoxin  of  tetanus, 
Behring 3  considers  that  a  third  body,  which  he  calls  the 
"  conductor,"  is  necessary  to  bring  about  combination,  this 
body  acting  in  the  same  manner  as  the  copula  in  haemolysis. 
If  this  is  proved  to  be  the  case  in  tetanus,  it  is  almost 
certain  that  the  interaction  of  other  toxins  and  antitoxins 
will  be  found  to  take  place  in  the  same  manner.  A 
somewhat  similar  view  is  propounded  by  Bordet  and  Gay  4 
in  the  case  of  diphtherial  toxin  and  antitoxin. 

Some  interesting  experiments  by  Donitz  ~>  throw  light 
on  the  action  of  toxin  and  antitoxin  within  the  body  of  a 
living  animal.  This  observer  found  that  if  a  dose  of  toxin 
was  injected  into  a  rabbit,  it  would  be  neutralized  by  the 
same  amount  of  antitoxin  which  would  neutralize  it  in 
vitro,  provided  that  the  latter  were  given  within  a  space  of 
nine  minutes.  If  more  than  this  time  had  elapsed,  it  was 
necessary  to  administer  a  considerably  larger  dose  of  the 
antitoxin ;  but  if  this  larger  quantity  were  given,  it  was 
still  possible  to  prevent  the  appearance  of  any  serious  ill 
effects.  If,  however,  a  space  of  time  exceeding  about  two 
hours  were  allowed  to  pass  after  the  toxin  had  been  given 
and  before  the  antitoxin  was  injected,  no  amount  of  the 
latter  would  suffice  to  avert  a  fatal  issue.  It  would  appear 
from  this  that  we  can  distinguish  three  separate  periods 
corresponding  with  distinct  stages  in  the  process  of  intoxi- 

1  Berlin,  khn.  Woch.,  1905,  xlii.  1368. 

2  Beitr.  z.  exper.  Therap.,  1905,  Hft.  18-41. 

3  Seat.  med.  Woch.,  Aug.  27,  1903. 

4  Ann.  deVInst.  Pasteur,  1906,  xx.  467. 

5  Arch.  Internat.  de  Pharmacodyn.,  Bd.  5,  1899. 


TOXIN   AND    ANTITOXIN  107 

cation:  (1)  At  first  the  poison  is  circulating  in  the  blood, 
and  has  not  yet  attacked  the  cells.  (2)  Later  on  it  has 
entered  into  some  sort  of  combination  with  them,  but  this 
is  so  loose  that  the  presence  of  a  large  quantity  of  anti- 
toxin is  capable  of  withdrawing  the  toxin  from  them 
again.  (3)  The  toxin  has  become  so  firmly  fixed  to  the 
cells  that  no  amount  of  the  remedy  is  capable  of  undoing 
the  combination.  What  constitutes  the  difference  between 
the  last  two  stages  is  unknown.  Perhaps  in  the  former  of 
the  two  the  toxin  has  only  attached  itself  to  the  side- 
chains,  whereas  in  the  latter  it  has  entered  into  combina- 
tion with  the  whole  body  of  the  cell- protoplasm. 

The  experiments  just  recorded  point  to  the  necessity 
for  the  early  administration  of  antitoxin  when  used  as  a 
remedy  for  diphtheria.  It  is  important  to  give  it  before 
the  poison  has  gained  so  firm  a  hold  upon  the  cells  that  it 
can  no  longer  be  withdrawn.  It  is  fortunate  that  diphtheria 
is  a  disease  in  which  it  is  possible  to  recognize  the  existence 
of  infection  at  a  comparatively  early  stage,  since  the  false 
membrane  appears  on  the  fauces  some  time  before  any  pro- 
found intoxication  of  the  entire  system  has  taken  place. 
To  this  fact  is  due,  no  doubt,  the  infinitely  greater  success 
that  has  attended  the  use  of  diphtherial  antitoxin  as  com- 
pared with  that  prepared  for  tetanus.  In  the  latter  disease 
the  existence  of  the  infection  is  only  recognized  by  the  appear- 
ance of  the  symptoms  of  general  intoxication.  It  is  then, 
in  many  cases,  already  too  late  to  hope  for  good  results 
from  the  administration  of  antitoxin.  Statistics  are  given 
later  (p.  1 26)  which  afford  incontrovertible  clinical  evidence 
of  the  value  of  early  injection  of  diphtherial  antitoxin. 

Strength  of  antitoxic  serum. — For  human  use  it 

is  important  to  possess  a  serum  containing  a  large  number 
of  antitoxic  units  in  a  small  volume,  since  it  is  not 
desirable  to  inject  a  larger  quantity  of  the  fluid  than  is 
absolutely  necessary.  Not  only  does  the  injection  of  a  large 
dose  cause  a  considerable  local  swelling,  which  is  only 
slowly  absorbed,  but  the  various  unpleasant  effects  which 


108       SERUMS,   VACCINES,    AND    TOXINS 

at  times  follow  an  injection  are  dependent  to  a  great  extent 
on  the  actual  volume  of  the  serum  which  is  administered. 
The  majority  of  serums  on  the  market  contain  300  to  500 
units  in  each  cubic  centimetre.  Hence  it  is  not  often 
necessary  to  give  more  than  10  c.c.  for  a  dose.  Stronger 
specimens  can  be  obtained  at  a  higher  price.  Diphtherial 
antitoxin  is  generally  supplied  in  liquid  form,  made  up 
with  a  little  antiseptic  as  a  preservative.  It  can  also  be 
obtained  in  the  desiccated  form.  According  to  Chiadini l 
it  appears  to  keep  well  for  a  period  of  at  least  eighteen 
months ;  after  two  years  it  begins  to  deteriorate  a  little, 
but  still  possesses  considerable  antitoxic  power ;  after  four 
years  it  is  valueless.  Ordinary  degrees  of  light  and  heat 
do  not  affect  its  potency,  nor  does  the  addition  of  anti- 
septic agents.  MacConkey  states  that  it  loses  strength 
six  times  as  quickly  at  36°  C.  as  at  0°  C.2 

Refined  antitoxin. — Gibson3  endeavoured  to  separate 
the  antitoxin  from  the  other  constituents  of  the  serum, 
by  precipitation  of  the  pseudo-globulin,  which  was  redis- 
solved  and  named  "  refined  antitoxin."  This  preparation 
is  said  to  retain  the  full  antitoxic  value  of  the  original 
serum,  and  to  be  equally  useful  in  the  treatment  of  diph- 
theria. It  also  keeps  well  (Park  and  Throne).  A  very 
similar  preparation  has  been  introduced  by  Brieger  and 
Krause.4 

Value  of  antitoxin. — It  is  extremely  difficult  to 
obtain  definite  proof  of  the  curative  value  of  any  drug, 
since  the  course  of  almost  every  disease  is  variable,  and 
sudden  improvements  and  relapses  are  liable  to  occur  from 
natural  causes,  apart  from  the  action  of  any  remedy.  The 
fluctuations  are  often  ascribed  to  any  drug  which  is  being 
administered  at  the  time,  and  there  is  no  means  by  which 
the  question,  Post  hoc  or  Propter  hoc  ?  can  be  decided.  In  the 

1  Gaz.  degli  Ospedali,  1902,  No.  60. 

;  Journ.  of  Hygiene,  191'2,  xii.  511. 

3  Journ.  Biol.  Chem.,  1906,  i.  161. 

4  Bcrl  klin.  ll'och.,  1907,  p.  946. 


VALUE   OF  ANTITOXIN  109 

cise  of  diphtheria  the  natural  variations  of  the  disease  are 
even  more  marked  than  in  many  other  disorders,  and  it  is 
impossible  to  judge  of  the  efficacy  of  antitoxin  with  any 
approach  to  accuracy  in  individual  cases. 

Dependence  must  therefore  be  placed  to  a  great  extent 
on  collected  statistics.  Even  here  a  manifest  source  of 
fallacy  is  introduced  by  the  undoubted  fact  that  infective 
diseases  exhibit  great  fluctuations  in  virulence  when  viewed 
over  considerable  periods  of  time,  the  mortality  from  them 
rising  and  falling  in  accordance  with  obscure  periodic  laws 
which  are  not  well  understood.  Hence  a  fall  in  the  mor- 
tality of  an  infective  disease  may  occur  apart  from  any  new 
remedy  which  has  come  into  vogue  during  the  period  of 
time  under  consideration.  In  the  case  of  diphtheria  there  is 
reason  to  believe  that  the  disease  has  become  more  common 
in  recent  years,  and  also  that  the  type  of  case  seen  is,  on 
the  whole,  less  virulent  l — apart  from  the  use  of  antitoxin 
—than  used  to  be  the  case.  It  does  not  seem,  therefore,  to 
be  logical  to  ascribe  to  this  remedy  all  the  reduction 
which  has  undoubtedly  taken  place  in  the  mortality  from 
diphtheria.  We  have  to  remember  also  that,  as  previously 
stated,  there  is  a  tendency  to  class  as  diphtheria,  owing  to 
the  mere  presence  of  B.  diphtherice  in  the  throat,  cases 
which  in  earlier  days  would  not  have  been  considered  to  be 
suffering  from  this  disease  (e.g.  cases  of  mild  sore-throat 
without  any  formation  of  membrane,  which  would  in  all 
probability  recover  without  any  treatment)  ;  such  instances 
swell  the  number  of  cases  of  diphtheria  without  adding  to 
the  deaths  which  occur,  thus  reducing  the  rate  of  mortality. 
All  these  facts  must  be  taken  into  account  when  we 
endeavour  to  form  a  scientific  judgment  as  to  the  inter- 
pretation to  be  placed  upon  the  available  statistics  with 
regard  to  the  influence  of  antitoxin  on  the  course  of  diph- 
theria With  this  preliminary  caution  we  may  proceed  to 
consider  the  figures  actually  given  by  different  authorities. 

1  This  seems  to  occur  with  all  infective  diseases — as  they  become 
more  widely  spread,  so  they  diminish  in  virulence. 


110       SERUMS,    VACCINES,    AND    TOXINS 

A  very  instructive  table  is  to  be  found  in  the  Reports 
of  the  Metropolitan  Asylums  Board,  giving  the  total  number 
of  admissions  of  cases  suffering  from  each  of  the  notifi- 
able diseases,  and  the  mortality  which  occurred  in  the 
Board's  hospitals  and  throughout  the  country  in  each  class. 
From  it  we  extract  the  following  data  with  regard  to 
diphtheria. 

From  the  table  (p.  Ill)  we  see  that  a  very  marked 
diminution  has  occurred  in  the  case- mortality  in  the 
hospitals  under  the  Metropolitan  Asylums  Board  since  the 
use  of  antitoxin  became  general.  Reasons  have  already 
been  given  for  thinking  that  not  all  of  this  apparent 
diminution  can  be  rightly  attributed  to  the  new  remedy, 
and  if  these  statistics  stood  by  themselves  some  doubt  might 
still  exist  as  to  the  value  of  antitoxin.  But  these  figures 
are  confirmed  by  reference  to  those  obtainable  from  other 
parts  of  the  country  and  of  the  world.  Almost  everywhere 
the  mortality  from  diphtheria  seems  to  have  fallen  at 
about  the  same  time,  and  this  simultaneous  effect  can 
hardly  be  entirely  a  coincidence. 

It  is  noteworthy  that,  while  the  case-mortality  in  these 
hospitals  has  so  distinctly  fallen,  as  shown  by  the  table,  yet 
the  mortality  throughout  the  country  generally  did  not 
decrease  up  to  1901.  Since  that  date  both  the  general  and 
the  hospital  mortality  have  fallen  notably.  This  decline 
cannot,  however,  be  altogether  attributed  to  the  use  of 
serum,  for  the  general  mortality  for  the  years  1871-6  was 
only  (HI  ;  that  for  the  following  six  years,  0-15  ;  and  that 
for  the  next  five  years,  0'23.  There  is  clearly  a  rise  and 
fall  in  the  mortality  apart  from  the  use  of  any  particular 
remedy. 

To  show  that  the  fall  in  diphtheria-mortality  has  been 
general-  throughout  the  world  and  not  confined  to  any  one 
place,  it  may  be  worth  while  to  quote  statistics  derived  from 
a  variety  of  sources.  Speaking  of  New  York,  Billings l 
states  that  since  the  introduction  of  antitoxin  a  steady  fall 
1  New  York  Med.  Joiirn.,  Feb.  17,  1900. 


DIPHTHERIA    STATISTICS 


111 


TABLE  1  SHOWING  ADMISSIONS  FOR  DIPHTHERIA  TO  METROPOLITAN 
ASYLUMS  BOARD  HOSPITALS  FOR  THE  YEARS  1888-1913,  WITH 
MORTALITY-RATE  IN  THESE  HOSPITALS  AND  THROUGHOUT  THE 
COUNTRY 


Year 

Admissions 

Deaths 

Percentage  mortality 
in  hospital 

Annual  mortality 
per  1,000  estimated 
population  . 

1888 

99  2 

46  " 

59-352 

0-32^ 

1889 

722 

275 

40-74^ 

**  o£ 

039 

^n    . 

1890 

942 

316 

33-55 

o  ftg 

0-33 

1891 

1,312 

397 

30-63 

•  Sols. 

0-32 

1892 

2,009 

583 

29-35 

£  £^ 

0-46 

CD  T- 
11 

1893 

2.848 

865 

30-42^ 

*M 

0-76J 

~  >, 

1894s 

3,666 

1,035 

29-29 

0-62 

1895 

3,635 

820 

22-85^1 

0-54^ 

1896 

4,508 

948 

21-20 

t~'a-^ 

0-60 

*~  ft  , 

1897 

5,673 

987 

17-69 

°-S| 

0-51 

°  ^    ' 

1898 

6,566 

991 

15-37 

y>  ni  v 
-  to   .  t, 

0-39 

-gjO  g 

1899 

8,676 

1,182 

13-95 

03    X    rtj 

£  S  ft 

0-43 

«  2"  ° 

1900 

7,873 

988 

12-27 

>  ?  to 

0-34 

^  «8 

1901 

7,622 

849 

11-15. 

0-29_ 

1902 

6,520 

739 

ll-(K'o 

0.25, 

1903 

5,072 

504 

9-7  h=^ 

0-16 

1904 

4,687 

469 

iooLc:g 

0-16 

i-8,rf« 

1905 

4,148 

347 

8-3  1  sis 

0-12 

1906 

5,218 

445 

8  "8  1  aj  >>  ft 

0-15 

a;  OJ  ft 

1907 

5,744 

544 

0-16> 

1908 

5,230 

507 

*7\« 

0  15> 

1909 

4,393 

432 

9-4  U-®. 

0-13 

1910 

3,634 

281 

7*15  .1 

0-09 

1911 

5,034 

428 

8'4|  £§& 

0-14 

ill's 

1912 

4,844 

331 

6-2     >  £§. 

0-10 

1913 

5,076 

330 

6'2J  * 

0'09> 

1  Extracted  from  the  Report  of  the  Statistical  Committee  of  the 
Metropolitan  Asylums  Board.     Annual  Report,  1913,  p.  154. 

2  Number  of  cases  too  small  to  be  of  value.     These  figures  are 
therefore  neglected  in  computing  averages. 

3  Treatment  with  antitoxin  introduced  during  this  year. 


112       SERUMS,    VACCINES,    AND    TOXINS 


in  both  the  number  of  cases  and  the  number  of  deaths  took 
place.  He  gives  the  following  table,  which  may  be  com- 
pared with  that  on  p.  111. 

MORTALITY  iv  NEAV  YORK  BEFORE  AND  AFTER  THE  INTRODUCTION 
OF  ANTITOXIN  (BILLINGS) 


Year 

Cases 

Deaths 

Mortality 
per  cent. 

1891 

5,364 

1,970                        36-7 

1892 

5,184 

2,196                        40-6 

1893 

7,021 

2,558 

36-4 

1894 

9,641 

2,870 

29-7 

1895' 

10,353 

1,976 

19-1 

18962 

11,399 

1,763 

15-4 

1897 

10,896 

1,590 

14-6 

1898 

7,593 

923 

12-2 

18993 

8,240 

1,087 

13-1 

The  death-rate  per  10,000  inhabitants  previous  to  the 
advent  of  antitoxin  was,  according  to  Park,  from  15  to  18 '8. 
After  its  introduction  it  fell  to  7,  the  average  number  of 
deaths  in  New  York  falling  from  2,733  to  1,341  (taking  the 
averages  of  fifteen  years  before  and  four  years  after  anti- 
toxin). In  Berlin4  the  average  of  deaths  per  100,000 
inhabitants  in  pre-antitoxin  days  was  90  6  :  it  fell  to 
38 '5  in  the  five  succeeding  years.  In  Paris  the  fall  was 
from  6 2 '2  to  13' 3.  It  cannot  be  maintained,  indeed,  that 
all  this  reduction  in  mortality  was  due  to  antitoxin ; 
sanitary  measures  probably  helped  to  reduce  the  death-rate, 
and  the  virulence  of  the  disease  may  have  diminished  ;  but 
the  coincidence  of  a  fall  all  over  the  world  about  the  time 
of  the  introduction  of  antitoxin  is  too  remarkable  to  be 
altogether  accidental. 

With  regard  to  case-mortality,  Rosenthal 5  collected 
from  various  sources  figures  showing  that  of  183,256  cases 

1  Antitoxin  introduced. 

2  Use  of  antitoxin  became  general. 

3  We  have  not  been  able  to  find  statistics  for  more  recent  years. 

4  Cobbett,  Edinburgh  Med.  Journ.,  1900,  i.  521. 
6  Med.  Press  and  Circ.,  1900,  ii.  293. 


VALUE   OF   ANTITOXIN  113 

treated  before  antitoxin  was  introduced  the  mortality- 
amounted  to  384  per  cent.  Among  132,548  cases  after  its 
use  become  general  the  mortality  was  only  14'6.  Felix1 
states  that  in  Roumania,  before  the  remedy  was  known,  the 
mortality  of  diphtherial  cases  was  from  41  to  63  per  cent.; 
the  introduction  of  antitoxin  has  reduced  the  fatality 
among  cases  treated  with  serum  to  1 2  per  cent.  Jaeger 2 
states  that  in  Miilhausen  the  death-rate  was  52  to  55  per 
cent,  in  ordinary  cases  and  65  to  68  per  cent,  in  laryngeal 
cases  in  pre-antitoxin  days;  whereas  it  fell  to  16  to  20 
per  cent,  and  20  to  25  per  cent,  respectively  after  the 
use  of  antitoxin  became  general.  Similarly  for  Vienna 
Siegert  3  states  that : 

From  1892-4,  of  4,894  cases  of  diphtheria,  over  2,000 

died  ;  mortality  nearly  50  per  cent. 
From  1895-7,  of  4,143  cases  of  diphtheria,  only  817 

died ;  mortality  about  25  per  cent. 

Enough  has  now. been  said  to  show  that  the  diminution 
in  mortality  is  not  confined  to  any  one  part  of  the  world. 
Other  evidence  in  favour  of  the  remedy  may  be  quoted  of 
an  even  more  convincing  nature. 

When  diphtheria  affects  the  larynx  the  cases  are 
generally  more  severe  than  those  which  are  confined  to  the 
fauces.  Goodall4  gives  some  figures  as  to  the  efficacy  of 
antitoxin  in  these  cases.  Before  the  days  of  antitoxin, 
of  3,275  cases  of  lavyngeal  diphtheria,  1,008  recovered  (33 -8 
per  cent.),  giving  a  mortality  of  66 '2  per  cent.  After  the 
introduction  of  the  remedy,  of  3,486  cases  of  the  same 
nature,  2,522  recovered  (72'3  per  cent.),  a  mortality  of 
27*7  per  cent.  Taking  cases  of  tracheotomy,  the  pre-anti- 
toxin rate  of  recovery  was  under  30  per  cent. ;  after  serum- 

1  SpitaluL,  1902,  No.  5  (Abstr.  in  Cenlralbl.  f.  inn.  Med.,  1902, 
p.  799). 

2  Deut.  Arch.f.  klin.  Med.,  Ixxiii. 

3  Jahrbuch  f.  Kinderhevlk.,  Jan.,  1902. 

4  Brit.  Med.  Journ.,  1899,  i.  197. 

I 


114       SERUMS,    VACCINES,    AND    TOXINS 

treatment  was  inaugurated,  the  percentage  of  recoveries  rose 
to  634  per  cent.  The  improvement  is  very  remarkable. 
Goodall  concludes  :  "  Whereas  in  the  pre-antitoxin  days, 
of  100  tracheotomies  you  could  not  expect  to  save  more 
than  29,  you  can  now  expect  to  save  no  fewer  than  53.  ... 
I  think  I  am  fully  justified  in  claiming  for  antitoxin  the 
great  reduction  in  mortality  among  cases  of  laryngeal 
diphtheria  that  these  figures  reveal." 

Park  '  records  802  laryngeal  cases  with  a  mortality  of 
23  per  cent.,  and  Piekema3  369  cases  of  tracheotomy  or 
intubation  with  28-2  per  cent,  of  deaths.  Both  these 
authors  ascribe  the  success  met  with  to  the  use  of  anti- 
toxin. 

Still  more  conclusive  evidence  is  afforded  by  the 
statistics  of  the  comparative  rates  of  mortality  in  cases 
in  which  the  remedy  is  administered  early  in  the  disease, 
and  in  those  in  which  a  delay  of  some  days  has  occurred. 
The  reason  for  this  has  been  already  pointed  out  (p.  46). 

The  table  on  p.  115  gives  the  results  obtained  by  the 
Collective  Investigation  Committee  of  the  American  Pedi- 
atric  Society  3  (1896). 

The  records  of  the  Brook  Hospital,  under  the  Metro- 
politan Asylums  Board,  show  very  similar  results.4  Thus 
in  the  years  1897-1907  (inclusive)  250  cases  were  treated 
on  the  first  day  of  the  disease,  without  a  single  death  ; 
of  1,513  cases  treated  on  the  second  day  the  mortality 
was  4-29  per  cent. ;  -among  1,690  treated  on  the  third  day, 
11-24  per  cent.;  among  1,338  treated  on  the  fourth  day, 
16 '89  per  cent.  ;  and  among  1,765  cases  treated  on  the  fifth 
and  subsequent  days  it  was  18-58  per  cent. 

1  Jotirn.  of  the  Amer.  Med.  Assoc.,  1900,  April  14,  p.  902. 

2  Inaugural  Dissertation,  Utrecht,  1900  (Abstr.  in  Centralbl.f.  inn. 
Med.,  1902,  p.  799). 

3  Joum.   of  the  Amer.    Med.    Assoe.,    1896,    ii.   27.      Cf.    Biggs, 
Med.  News,  1899,  July  22  and  29,  pp.   97  and  137 ;  Larkins,  Jonrn. 
Amer.  Med.  As.«oc.,  1899,  p.  7  ;  Park,  iliil,  1900,  April  14,  p.  902. 

4  M.A.P.  Kept.,  1907,  p.  105. 


VALUE   OF    ANTITOXIN 


115 


§1 


0  « 

*>  2 

H  S 

co  p 

•<  S 


fe  =  c  t~     <o 
o^Ss^     i 


MacConkey,1  the  com- 
piler of  these  statistics, 
gives  similar  figures  for 
the  years  1912-13,  which, 
taken  together,  show  69 
cases  treated  on  the  first 
day  with  no  deaths  ;  288 
on  the  second  day  with  9 
deaths,  or  31  per  cent.  ; 
290  on  the  third  day  with 
25  deaths,  or  8'6  per  cent. ; 
218  on  the  fourth  day  with 
27  deaths,  or  12-35  per 
cent. ;  and  332  on  subse- 
quent days  with  27  deaths, 
or  8*1  per  cent. — this  last 
smaller  percentage  being 
probably  due  to  the  in- 
clusion of  slight  cases,  only 
recognized  late  as  being 
diphtheria  at  all.  Thus 
for  eleven  years  no  death 
occurred,  in  this  author's 
experience,  among  the  cases 
treated  on  the  first  day  of 
the  disease. 

The  agreement  shown 
among  these  sets  of  figures 
is  very  striking.  There  is 
invariably  a  progressive 
increase  in  the  mortality 
as  the  remedy  is  given 
later  and  later  after  the 
onset  of  the  attack.  No 

stronger  evidence  could  be  found  in  favour  of  the  use  of  anti- 
toxin in  this  malady,  for  there  is  absolutely  no  explanation 
1  M.A.1L  Kept.,  1912,  p.  192,  and  1913,  p.  179. 


ftn«?J   •*        CO        0 


116       SERUMS,    VACCINES,    AND    TOXINS 

which  we  can  adduce  for  this  steadily  increasing  death- 
rate  according  to  the  delay  in  the  use  of  the  remedy,  other 
than  the  hypothesis  of  its  curative  power  when  adminis- 
tered sufficiently  early.  This  accords  exactly  with  what  is 
theoretically  to  be  expected  of  the  serum  and  with  ex- 
perimental results  obtained  on  the  lower  animals. 

While  pronouncing  thus  unhesitatingly  in  favour  of  the 
use  of  antitoxin,  it  is  necessary  to  bear  in  mind  that  some 
authorities  who  have  had  good  opportunities  of  judging 
of  its  value  are  sceptical  as  to  its  usefulness.  Among 
American  writers  we  may  mention  Hermann  l  and  Rupp,2 
both  of  whom  decline  to  subscribe  to  the  general  verdict 
in  favour  of  the  remedy.  On  the  continent  of  Europe 
Kassowitz  3  was  equally  opposed  to  the  prevailing  view.  He 
pointed  out  that,  although  a  fall  in  the  mortality  from  diph- 
theria was  experienced  in  many  parts  of  the  world  syn- 
chronously with  the  introduction  of  antitoxin,  yet  latterly 
the  death-rate  had  risen  again  in  many  places  in  spite  of  its 
continued  use;  hence  the  fall  in  the  death-rate  could  not 
be  ascribed  to  the  antitoxin.  There  is  much  truth  in  this 
argument,  as  has  already  been  admitted  ;  and  if  we  had 
only  this  means  of  judging  of  the  value  of  antitoxin,  it 
would  be  necessary  to  return  a  verdict  of  "  not  proven." 
But  the  evidence  available  as  to  the  progressively  greater 
mortality  in  cases  of  diphtheria,  according  as  they  are 
left  for  increasing  periods  of  time  without  antitoxin,  ap- 
pears to  constitute  irrefragable  proof  of  the  value  of  the 
remedy ;  and  the  expression  of  doubt  as  to  its  efficacy 
becomes  increasingly  rare  in  medical  writings. 

Mode  of  administration  of  antitoxin. — As  a  rule 

diphtherial  antitoxin  is  administered  subcutaneously,  but  it 
may  be  injected  intramuscularly  (Rolleston  speaks  highly 
of  this  method)  or  intravenously  (see  pp.  51,  55). 

It  would  seem  advisable  to  make  use  of  the  intravenous 

1  Med.  Record,  Jan.  20,  1900. 

2  New  York  Med.  Journ.,  Jan.  27,  1900. 

3  Therapeut.  Monatsh.,  1902,  pp.  223,  499. 


ADMINISTRATION   OF   ANTITOXIN        117 

method  of  injection  in  cases  in  which  the  symptoms  are 
severe,  and  especially  in  those  in  which  the  use  of  the  serum 
has  been  unduly  postponed.  Good  results  are  reported  by 
Cairns1  from  this  mode  of  procedure,  very  large  doses  of 
antitoxin  being  used  in  some  cases  (see  below). 

The  antitoxin  has  also  been  given  by  some  physicians 
by  the  rectum  and  by  the  mouth.  Dominicis  2  was  one  of 
the  first  to  adopt  these  procedures,  and  reported  five 
successful  cases.  Parkinson3  states  that  rectal  adminis- 
tration has  been  carried  out  at  the  London  Temperance 
Hospital,  and  that  the  results  obtained  have  been  very 
satisfactory.  He  recommends  this  method  as  being  free 
from  some  of  the  disadvantages  of  subcutaneous  injection, 
such  as  local  abscess-formation,  which  sometimes  follow 
neglect  of  aseptic  precautions.  Paton,4  who  advises  the  use 
of  diphtherial  antitoxin  in  septic  conditions  not  due  to  the 
B.  diphtkerice,  administers  the  remedy  by  the  mouth,  stat- 
ing that  it  is  not  affected  by  digestion ;  and  Zahorsky 5 
advises  the  administration  of  antitoxin  in  milk  to  children 
when  a  prophylactic  dose  is  needed.  Pilcher  6  also  commends 
the  oral  method  of  administration,  and  Chantemesse  7  has 
given  antitoxin  by  the  rectum  with  satisfactory  results. 
On  the  other  hand,  the  results  of  experiments,  from  which 
mild  infections  and  the  possibility  of  coincidence  have  been 
carefully  eliminated,  show  that  this  procedure  (see  p.  50) 
is  ineffective  and  unscientific  ;  and  since  there  is  no  doubt 
that  antitoxin  acts  well  when  administered  by  hypodermic 
injection,  while  the  drawbacks  to  this  method  are  very  in- 
significant, it  seems  wiser  to  use  it  (or  the  intravenous  or 
the  intramuscular  method)  for  treatment  in  all  cases. 

1  Lancet,  1902,  ii.  1685. 

2  Gaz.  degli  Ospedali,  July  19,  1896. 

3  Brit.  Med.  Journ.,  1903,  i.  1432. 

4  Australas.  Med.  Gazette,  1902,  Feb.  20. 

5  Archives  of  Pediatrics,  March,  1899. 
8  Brit.  Med.  Journ.,  1904,  ii.  1751. 

7  Sem.  Med.,  July,  1896. 


118       SERUMS,    VACCINE'S,    AND    TOXINS 

Prophylactic  Use  Of  antitoxin. — It  has  been  ascer- 
tained beyond  reasonable  doubt  that  the  administration 
of  a  comparatively  small  djse  of  antitoxin  will  produce 
immunity  to  the  disease  for  a  certain  period  of  time. 
Ronald  French  made  a  series  of  observations  upon  nurses 
to  whom  3,000  units  of  antitoxin — an  excessive  prophylactic 
dose — were  administered  before  they  went  on  duty  in  diph- 
theria wards,  and  found  that  the  diphtherial  opsonin-index 
at  first  rose  rapidly,  reached  a  maximum  in  from  4  to  1 1 
days,  then  fell  to  a  point  below  the  normal,  and  returned  to 
the  normal  in  about  3  weeks  after  the  injection.  Netter l 
originally  showed  that  the  protection  begins  about  the  end 
of  the  first  day  (24  hours)  after  the  injection,  and  lasts 
for  about  3  weeks.  Beyer  2  states  that  after  24  hours  the 
amount  of  antitoxin  present  in  the  blood  is  only  one-half 
to  five-sixths  of  the  amount  injected ;  after  2  to  4  days 
about  one-quarter  to  one-half  the  quantity  remains ;  after 
5  or  6  days  there  is  still  one-third  to  one-quarter ;  and 
none  is  present  at  the  end  of  3  weeks.  The  protective 
substance  is  possibly  excreted  in  the  urine,  etc.,  or  possibly 
anti-antitoxins  or  destructive  ferments  may  be  formed. 
There  seems  no  reason  to  hold  that  the  length  of  the 
immunity  is  at  all  proportional  to  the  dose  administered. 

In  the  presence  of  an  epidemic  of  diphtheria,  among  491 
children  exposed  to  infection,  who  did  not  receive  protective 
injections,  87  contracted  the  disease  ;  while  of  502  children, 
who  had  been  similarly  exposed  and  were  given  protective 
injections,  only  13  became  infected.  Of  these,  7  developed 
the  disease  within  24  hours,  and  6  more  than  a  month  after 
the  injections.  Since  the  immunity  does  not  begin  for 
24  hours  and  passes  off  in  approximately  3  weeks,  these 
figures  strongly  support  the  prophylactic  use  of  the 
remedy.3 

As  a  result  of  Netter's  communication  and  the  discussion 

1  Bull,  de  VAcad.  de  Med.,  Paris,  March  18,  1902 

2  Deut.  ined.  Woch.,  1912,  No.  50. 
*  Netter,  loe.  cit. 


ANTITOXIN    IN    PROPHYLAXIS  119 

which  followed  ib,  the  Academy  of  Medicine  (Paris)  passed 
resolutions  l  to  the  following  effect : — 

1.  Preventive  injections  of  1,000,  or  at  most  2,000, 

units  of  diphtherial  antitoxin  produce  immunity 
to  the  disease.  This  protection  is  transitory  in 
character. 

2.  Such   preventive   injections   are   especially  to  be 

recommended  in  the  members  of  families  in 
which  cases  of  diphtheria  have  occurred,  in  order 
to  immunize  the  other  children. 

3.  They  are  also  called  for  in  schools,  creches,  hospi- 

tals, etc.,  where  children  are  collected  together-  so 
that  infection  is  easily  spread  from  one  to  another. 

4.  Injections   of    antitoxin    are    useful    in    patients 

suffering  from  scarlet  fever  and  measles,  in  which 
affections  diphtheria  is  a  frequent  complication. 

5.  The  prophylactic  use  of   antitoxin  does  not  pre- 

clude the  carrying  out  of  ordinaiy  measures  of 
disinfection  and  isolation. 

American  writers  are  strongly  in  favour  of  the  preven- 
tive use  of  antitoxin.  Biggs2  states  that  out  of  3,109 
cases  in  which  this  was  given,  only  9  children  acquired 
diphtheria  ;  and  Park3  records  6,506  cases  of  immunization, 
among  which  28  developed  the  disease  within  24  hours, 
before  the  protection  'was  effective,  while  only  27  were 
attacked  after  this  limit  of  time,  of  whom  one  died  of  scarlet 
fever.  Billings 4  attributed  a  rise  which  had  occurred  in 
the  diphtheria-rate  to  the  neglect  of  the  prophylactic  use  of 
the  remedy. 

On  the  other  hand,  Violi 5  considers  that  antitoxin  is 
not  a  sure  preventive  of  diphtheria,  and  advises  that  it 

'  Brit.  Med.  Journ.,  1902,  j.  997. 

2  Quoted  by  Billings,  op.  cit. 

3  Journ.  oftheAmer.  Med.  Assoe.,  1900,  i.  902. 

4  New  York  Med.  Journ.,  1900,  Ixxi.  234. 

5  Fettiatria,  June,  1900. 


120       SERUMS,    VACCINES,    AND    TOXINS 

should  only  be  given  when  there  is  a  certainty  that  a 
child  has  been  exposed  to  infection.  The  difficulty  which 
exists  in  judging  of  the  value  of  any  prophylactic  has 
been  emphasized  by  Peters,1  who  records  instances  of 
failure  to  protect  persons  in  whose  fauces  the  B.  diphtheria 
had  actually  effected  a  lodgment.  Netter2  admits  that 
prophylactic  injections  need  not  be  given  if  the  children 
can  be  kept  under  observation  and  apart  from  others  whom 
they  might  infect. 

It  might  be  well,  owing  to  the  transient  nature  of  the 
immunity  obtained,  to  repeat  the  dose  if  the  epidemic  con- 
tinued, so  as  to  renew  the  protection.  Even  apart  from 
re-infection,  virulent  bacilli  have  been  known  to  remain 
present  in  the  throats  of  children  for  long  periods  of 
time. 

It  cannot  be  denied  that  there  is  a  real,  though  exceed- 
ingly small,  risk  in  the  administration  of  antitoxin.  Never- 
theless, as  500  units  is  an  efficient  prophylactic  dose,  and 
can  be  obtained  in  half  a  cubic  centimetre  of  serum,  even  in 
private  practice  among  well-to-do  patients  it  seems  advisable 
to  give  preventive  injections  as  a  routine  procedure.  In 
the  case  of  institutions,  such  as  schools  and  hospitals,  the 
wisdom  of  this  course  is  even  clearer ;  here  there  is  a 
very  great  liability  for  the  infection  to  spread  from  one 
patient  to  another,  and  this  precautionary  measure  seems 
imperatively  necessary.  It  is  well  to  remember  the  fre- 
quency with  which  epidemics  of  diphtheria  are  kept  alive  by 
means  of  children  who  are  the  subjects  of  chronic  nasal  dis- 
charges. This  condition  seems  to  have  little  effect  on  the 
health  of  the  child  itself,  but  the  virulent  bacilli  contained  in 
the  nasal  secretion  are  capable  of  infecting  others.  Hence, 
children  who  have  been  brought  into  contact  with  such 
"carriers"  must  be  looked  upon  as  having  been  exposed  to 
infection  and  treated  accordingly.  In  the  management  of 
epidemics  of  diphtheria,  particularly  those  which  may 

1  Brit.  Med.  Journ.,  1907,  ii.  865. 

2  Loc.  cit. 


ACTIVE    PROPHYLAXIS    IN   DIPHTHERIA   121 

be  designated  "school  epidemics,"  the  most  expeditious, 
economical,  and  efficient  method  is  undoubtedly  that  which 
includes  the  examination  of  swabbings  from  the  entire 
community,  segregation  of  all  carriers,  and  the  prophylactic 
injection  of  antitoxin  into  all  contacts. 

Active  prophylactic  immunization.— Behring1  has 

introduced  a  method  of  active  immunization  against  diph- 
theria, to  take  the  place  of  prophylactic  injections  of 
antitoxin.  He  makes  mixtures  of  toxin  and  antitoxin  of 
various  strengths,  called  respectively  MM1?  M1?  M2,  and 
M3,  the  exact  composition  of  which  we  have  not  been 
able  to  find  stated.  The  injections  are  given  subcutaneously 
or  intradermally  between  the  shoulders.  Local  redness 
and  infiltrations,  with  swelling  of  lymphatic  glands,  fever, 
and  headache,  are  produced  (Kleinschmidt  and  Viereck).2 
Kissling,3  who  gave  doses  of  0*1  to  0*3  c.c.  of  a  l-in-5 
solution  of  MMls  states  that  there  is  no  negative  phase,  but 
that  it  takes  some  days  for  immunity  to  develop.  He 
quotes  statistics  of  310  cases.  Of  these,  111  patients 
received  two  injections,  and  none  of  them  developed 
diphtheria,  while  199  received  only  one  injection,  and 
among  these  there  were  8  cases  of  infection,  but  3  of  these 
occurred  within  the  first  nine  days  after  treatment,  before 
immunity  could  be  supposed  to  be  complete.  There  is  not 
yet  available  sufficient  evidence  on  which  to  judge  of  the 
merits  of  Behring's  method.  It  is  difficult  to  believe  the 
statement  that  there  is  no  period  of  increased  susceptibility 
(negative  phase)  at  the  beginning  of  the  treatment. 

Dose  of  antitoxin. — The  tendency  at  the  present 
time  seems  to  be  in  the  direction  of  giving  large  doses  of 
antitoxin.  For  prophylactic  use  150  units  were  at  first 
generally  employed  in  America,  but  this  dose  was  found 
to  be  too  small,  and  the  Health  authorities4  there  now 

1  Congr.f.  inn.  Ned.,  Wiesbaden,  1913. 

2  Deut.  med.  Woch.,  1913.  p.  1977. 

3  Ibid.,  p.  2500. 

•*  Billings,  New  York  Med.  Journ.,  1900,  Ixxi.  234. 


122       SERUMS,    VACCINES,    AND    TOXINS 

recommend  the  use  of  not  less  than  300  units.  Jump  l 
recommends  250  units  for  children  under  2  years,  500 
for  older  children  and  adults.  The  Paris  Academy,  whose 
resolutions  were  alluded  to  on  p.  119,  speak  of  1,000  to 
2,000  units  as  a  protective  dose.  There  can  be  little  doubt 
that  these  last  are  unnecessarily  large.  Perhaps,  on  the 
ground  of  American  experience,  we  may  consider  that  300 
to  500  units  is  the  proper  dose — no  distinction  being  made 
between  children  and  adults;  or  if  a  distinction  is  made 
it  should  be  in  the  direction  of  an  increased  dose  for  the 
infant.  It  seems  advisable  to  repeat  the  dose,  if  liability 
to  infection  continues,  or  if  virulent  bacilli  should  still  be 
found  in  the  child's  throat. 

For  purposes  of  treatment  much  larger  amounts  are 
required.  Villy2  advises  that  in  cases  of  moderate  severity 
2,000  units  should  be  given  at  once  and  repeated  in  12 
hours,  if  necessary.  In  severe  cases,  8,000  to  12,000  units 
may  be  the  first  dose,  followed  by  2,000  to  8,000  units  every 
12  hours.  McCollom  3  gave  an  initial  dose  of  8,000  units 
in  a  severe  and  apparently  hopeless  case,  following  this  up 
with  4,000  units  some  hours  later,  and  repeating  the  dose 
every  4  to  6  hours,  till  92,000  units  in  all  had  been 
administered.  The  patient  recovered  completely.  Satter- 
thwaite  *  states  that  the  initial  dose  for  an  infant  under 
1  year  is  now  established  at  2,000  units ;  for  one  over 
1  year,  3,000  ;  and  for  an  adult,  4,000  to  6,000  units. 
Cairns  5  puts  the  doses  for  subcutaneous  injection  at  from 
4,000  to  20,000  units  ;  while  intravenously  he  administers 
from  20,000  to  35,000  units.  He  holds  that  in  severe  cases 
an  initial  dose  of  20,000  units  is  not  excessive.  Welden6 

1  Philad.  Med.  Joum.,  Jan.  11,  1902. 

2  Med.  C/tron.,  1900,  ii.  241. 

3  Quoted  by  Satterthwaite. 

*  Med.  News,  May  16,  1903,  p.  936. 

5  lancet,  1902,  ii.  1685. 

6  New  York  Med.  Joiirn.  and  Philadelphia  Med.  Jotirn.,  Nov.  14, 
1903.  p.  927. 


DOSE    OF   ANTITOXIN 


123 


finds  that  the  best  results  are  obtained  by  administering 
2,000  units  every  three  hours  until  the  severity  of  the 
symptoms  diminishes. 

DOSE    OF    DlPHTHERIAI,    ANTITOXIC    SERUM    (IN    UNITS) 
RECOMMENDED    BY    VARIOUS    WRITERS 


Author 

Mild  case 

Average  case 

Severe  case 

Prophylaxis 

Cohn  1  .     . 

1,000 



1,500-2,000 

— 

Baginsky  - 

1,500 

4,000 

5,000 

— 

Bishop  3    . 

(2,000  (adult) 
\4,000  (child) 

— 

12,000  (max.) 

— 

Rudolph  4  . 

— 

3,000  repeatd. 

— 

300-500 

Berg  5  .     . 

— 

3,000  repeatd. 

— 

— 

Pexa6  .     . 

— 

3,000 

— 

— 

Fischer  7  . 

2,000 

5,000 

10,000 

— 

tSonza  8 

— 

7,000 

— 

— 

McCollom9 

4,000 

8,000  repeatd. 

12,000  repd. 

— 

Berlin10    . 

— 

4,000-8,000 

16,000 

— 

Rolleslon  " 

{3,000-12,000 
I 

12,000-18,000 

18,000-24,000 
(repeated) 

— 

Park  12.     . 

6,000-10,000 

20.000-30,000 

— 

Ibrahim13. 

— 

— 

— 

250-500 

Wesener  u 

— 



_ 

300-400 

Aaser  15     . 

— 

— 

— 

300-400 

On  the  other  hand,  some  authorities  recommend  the  use 
of  small  doses  for  treatment.  Thus  Musser  le  advises  that 
children  from  6  to  8  years  old  should  receive  only  500  units, 

1  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  Bd.  xiii.,  Hft.  4  and  5. 
-Berlin,  klin.  Woch.,  1908,  p.  1257.' 

3  Brit.  Med.  Journ.,  1907,  ii.  1528. 

4  Ibid.,  1903,  i.  1078.  5  Med.  Record,  Nov.  26,  1904. 

6  Abstr.  in  Centralbl.f.  inn.  Med.,  1905,  p.  975. 

7  Med.  Record,  1904,  Ixvi.  875. 

8  Gas.  dos  Hospitales  do  Porto,  Aug.,  1907. 

9  Med.  Record,  loo.  cit.          10  Deut.  med.  Woch.,  1910,  No.  5. 

11  Practitioner,  1904,  Ixxiii.  615  et  seq. 

12  Boston  Med.  and  Surg.  Journ.,  Jan.  16,  1913. 

13  Dent.  med.  Woch.,  Mar.  16,  1905. 

14  Munch,  med.  Woch.,  1905,  No.  12. 

15  Berlin,  klin.  Woch.,  Sept.,  1905. 

16  University  Med.  Magazine  (Philadelphia),  March,  1900. 


124       SERUMS,    VACCINES,    AND    TOXINS 

while  those  over  8  should  have  1,000,  repeated  if  necessary 
in  8  to  12  hours.  Geffrier  and  Rozet J  also  recommend  that 
small  doses  should  be  used ;  and  these  writers  do  not 
advise  the  use  of  prophylactic  injections,  on  account  of  their 
occasional  bad  effects. 

Reiche  2  states  that  when  large  numbers  of  cases  are 
taken  for  statistical  purposes  no  advantage  appears  to  be 
derived  from  the  use  of  large  doses. 

Our  own  opinion  inclines  to  the  administration  of  an 
initial  subcutaneous  dose  of  2,000  units  for  an  infant,  and 
4,000  for  an  adult,  repeated  12  and  24  hours  later,  if 
necessary ;  this  may  be  accompanied,  if  the  case  is  a  very 
severe  one  or  is  first  seen  at  or  about  the  fifth  day,  by  an 
intravenous  injection  of  a  similar  amount. 

The  opinion  has  been  expressed  that  the  use  of  anti- 
toxin after  the  fifth  day  of  the  disease  is  ineffectual  and 
should  be  discontinued.3  Its  use  in  late  stages  has  even 
been  looked  upon  as  actively  harmful.  Such  views  are 
vigorously  combated  by  Rolleston,4  and  are  contrary  to  the 
accepted  theory  of  the  nature  of  the  disease.  We  believe 
that  in  any  severe  case  of  diphtheria  antitoxin  should  be 
administered  as  soon  as  the  case  comes  under  treatment.  In 
cases  of  relapse  serum  should  again  be  injected  in  spite  of  the 
probability  that  severe  symptoms  of  "  serum-disease  "  may 
ensue.  It  is  well,  however,  to  bear  in  mind  the  condition 
named  by  Rolleston  "  angina  redux  "  (the  angine  de  retour 
of  French  writers),  a  form  of  simple  tonsillitis  which  does 
not  call  for  specific  treatment  (see  p.  128). 

Antitoxin  and  post  -  diphtheritic  paralysis.— 
There  is  reason  to  believe  that  since  the  introduction  of 
antitoxin  the  percentage  of  cases  which  suffer  from  paraly- 
sis after  diphtheria  has  definitely  increased.  This  effect 
was  at  first  attributed  to  the  remedy,  and  some  prejudice 

1  Arch,  de  Med.  dcs  Enfants,  Feb.,  1900. 

2  Med.  Klinik,  1913,  pp.  11,  57. 

3  Bolton,  Lancet,  1907,  i.  870. 

4  Ibid.,  1907,  i.  1112. 


ANTITOXIN   AND    PARALYSIS  125 

against  the  use  of  it  was  thereby  excited.  Since,  however, 
as  we  have  just  endeavoured  to  prove,  it  saves  the  lives  of 
many  patients  who  would  otherwise  have  died,  and  these 
severe  cases  are  those  which  are  most  likely  to  exhibit 
paralysis  later  on,  there  inevitably  arises  an  increase  in  the 
percentage  of  cases  of  paralysis  ;  it  is  in  reality  a  testimony 
to  the  value  of  the  antitoxin,  and  not  a  drawback  to  its  use. 

With  regard  to  the  incidence  of  paralysis  after  diph- 
therial  intoxication,  Ransom l  comes  to  the  following  con- 
clusions as  the  result  of  experimental  researches  : — 

"  1.  Paralysis  may  certainly  be  expected  after  intoxica- 
tion with  not  less  than  one-quarter  of  a  minimal  fatal  dose. 
With  doses  between  one-quarter  and  one-eighth  of  this 
amount  paralyses  occur  but  are  not  constant,  and  below 
one-eighth  no  paralysis  was  noticed. 

"  2.  The  larger  the  dose  of  toxin  the  severer  will  be  the 
paralysis,  if  the  animal  survives  long  enough. 

"  3.  Neutralized  mixtures  of  toxin  and  antitoxin  con- 
taining only  about  one  lethal  dose  or  less  do  not  appear  to 
cause  paralysis. 

"4.  Antitoxin,  given  15  to  22  hours  after  intoxication 
with  doses  of.  toxin  not  greater  than  the  lethal  dose, 
exercises  in  large  doses  a  mollifying  influence  on  the  sub- 
sequent paralysis.  .  .  .  Small  doses  of  antitoxin  have  no 
evident  effect  in  diminishing  the  paralysis. 

"  5.  Transferring  the  results  to  practice  among  human 
beings,  we  may  expect  liberal  doses  of  antitoxin  given 
early  in  the  illness  to  influence  favourably  the  subsequent 
paralysis  ;  and  this  favourable  influence  is  likely  to  mani- 
fest itself,  not  so  much  in  the  local  paralyses  (soft  palate, 
etc.)  as  in  such  fatal  symptoms  as  failure  of  the  heart. 
Severe  cases  are,,  however,  likely  to  be  followed  by  some 
paralysis  in  spite  of  even  large  doses  of  antitoxin." 

It  would  appear,  then,  that  so  far  from  having  any  part 
in  the  production  of  paralysis,  antitoxin  has  some  power  of 
restraining  it.  These  results  are  in  accordance  with  those 
1  Journ.  of  Pathology  and  Bacteriology,  1900,  vi.  397. 


126       SERUMS,    VACCINES,    AND    TOXINS 


of  other  writers.1  Thus  Rosenau  and  Anderson  found  that 
in  guineapigs  one  unit  of  antitoxin  given  before  or  at 
the  time  of  infection  entirely  prevented  paralysis ;  that 
if  it  were  given  within  24  hours  it  modified  the  subse- 
quent paralysis ;  but  that  at  later  periods  it  had  no 
influence.  Comby,2  on  the  other  hand,  advises  the  use  of 
antitoxin  in  the  treatment  of  paralysis  which  has  actually 
occurred. 

PERCENTAGE  INCIDENCE  OF  PARALYSIS  ACCORDING  TO  DAY  or 
TREATMENT  WITH  ANTITOXIN  3 


Approximate  date 
of  treatment 

Petit 

Monti 

Reichsfald 

Rolleston 

1st  day 

_ 

_ 

5-5 

2nd 

6-25 

— 

25 

15-0<» 

3rd 

19 

8 

33 

18-07 

4th 

24-70 

12 

— 

28-07 

oth 

— 

33-3 

50 

35 

6th 

— 

50 

— 

34 

7th 

38-70 

66-2 

— 

19 

111  effects  Of  antitoxin. — The  manner  in  which  the 
injection  of  the  serum  of  any  species  of  animal  into  an 
individual  of  another  species  is  liable  to  be  followed  by 
toxic  symptoms  has  already  been  considered  (p.  55). 

It  cannot  be  denied  that  in  a  certain  number  of  in- 
stances the  injection  of  diphtherial  antitoxin  has  been 
followed  by  death,  directly  attributable  to  the  action  of  the 
serum.  A  melancholy  instance  was  afforded  by  the  sudden 
death  of  Professor  Langerhans'  infant  son  soon  after  a 
prophylactic  dose  of  the  serum,  but  this  has  been  attributed 

'  Malynicz  ("Ueber  d.  Hiiufigkeit  der  postdiphterischen  Lahmungen 
vor  u.  nach  Serum-behandlung,"  Zurich,  1908)  gives  statistics  to  show 
that  not  only  is  paralysis  more  common  after  serum  treatment,  but 
that  cardiac  paralysis  is  especially  common  and  fatal,  We  do  not 
think  that  this  is  the  usual  experience. 

-  Lancet,  1906,  i.  54,  243. 

s  Rosenau  and  Anderson,  Pub.  Health  and  Mar.  Hosp.  Si-rvico, 
U.S.A.  Bull.  Hyg.  Lab.,  No.  38,  1907. 


ILL   EFFECTS   OF   ANTITOXIN  127 

to  the  existence  in  the  child  of  the  status  lymphaticus,  which 
predisposes  to  death  from  trivial  causes.  A  similar  case  of 
sudden  death  is  recorded  by  Boone  l  in  a  boy  aged  10  years, 
who  after  an  injection  of  4,000  units  of  antitoxin  suddenly 
sat  up,  clutched  at  his  throat,  became  deeply  cyanosed,  and 
died.  No  cause  of  death  was  discovered  at  the  necropsy. 
Mackeen  2  reports  a  fatality  in  a  girl  aged  17,  the  subject 
of  asthma  and  status  lymphaticus  :  in  this  case  the  anti- 
toxin was  administered  as  a  prophylactic.  Most  of  the 
fatal  cases  recorded  have  been  of  the  same  sudden  character. 
A  case  in  which  death  took  place  at  a  later  period,  and 
was  due  to  the  same  vascular  disturbance  which  gives 
rise  to  the  rashes  often  seen  after  injections  of  antitoxin, 
is  recorded  by  Gerlach.3  In  this  instance  an  erythe- 
matous  eruption  appeared  on  the  eleventh  day  after  the 
injection  ;  on  the  twelfth  day  there  were  clonic  spasms, 
without  the  presence  of  albumin  in  the  urine  or  any 
symptoms  of  ursemia.  At  the  necropsy  there  was  found  an 
extradural  meningeal  haemorrhage,  which  was  attributed  to 
a  leakage  from  the  vessels,  analogous  to  the  escape  of  serum, 
and  sometimes  of  blood,  seen  in  erythema  multiforme. 
Gerlach  alludes  to  another  case  in  which  cerebral  symptoms 
came  on  after  an  injection,  but  which  did  not  end  fatally. 

Holladay  records  a  case4  in  which  a  man  of  26  received 
an  injection  of  only  500  units.  This  was  followed  by 
tingling  in  the  arm,  where  the  dose  had  been  adminis- 
tered, cyanosis,  constriction  at  the  chest,  and  collapse ; 
recovery  subsequently  ensued. 

Saward 5  records  2  cases  in  which  sudden  syncope 
occurred  after  injections  of  antitoxin.  It  must  be  re- 
membered, however,  that  the  toxin  of  diphtheria  acts  on 

1  Journ.  Amer.  Med.  A.SSOC.,  1908,  1.  453. 

-  Boston  Med.  and  Surg.  Journ.,  April  6,  1911. 

3  Therapeut.  Monatsh.,  April,  1903,  p.  198. 

4  Virginia  Med.  Semi-Monthly  (quoted  in  Indian  Lancet,  March  23, 
1903, p.  481). 

:'  Brit.  Med.  Journ.,  1902,  i.  1025. 


128       SERUMS,    VACCINES,    AND    TOXINS 

the  cardiac  muscle,  producing  a  tendency  to  syncopal 
attacks ;  it  is  therefore  very  doubtful  whether  these  cases 
were  really  to  be  attributed  to  the  antitoxin,  since  they 
might  equally  well  have  been  caused  by  the  disease  itself. 

An  exudative  tonsillitis  may  occur  as  a  serum  - 
phenomenon  (angina  redux,  Rolleston),  and  may  give  rise  to 
fears  of  a  relapse  ;  there  are,  however,  no  diphtheria  bacilli 
in  the  exudate,  and  this  is  not  a  distinct  membrane  but  a 
soft  deposit.  It  is  important  to  distinguish  this  condition, 
which  only  occurs  with  other  manifestations  of  serum  disease, 
from  a  true  relapse,  as  it  would  obviously  be  improper  to 
inject  more  antitoxin. 

Swelling  Of  the  Cervical  glands  is  another  rare 
effect  of  serum  treatment.  Bolton J  alludes  to  the  occur- 
rence of  abscesses  at  the  site  of  injection,  and  in  one  case 
necrosis  of  the  overlying  skin.  Such  incidents  are,  how- 
ever, probably  due  to  some  failure  of  antiseptic  pre 
cautions. 

The  most  frequent  ill  effects  brought  about  by  injection  of 
serum  are  cutaneous  eruptions  2  (see  also  p.  57).  Park  3 
observed  them  in  3  per  cent,  of  his  cases,  Stanley  4  in  over 
25  per  cent.,  and  Villy  5  in  35-2  per  cent.  The  rashes  are 
generally  classified  as  (1)  erythematous,  (2)  scarlatiniform, 
(3)  morbilliform,  and  (4)  urticarial.  They  are  all  mani- 
festations of  a  condition  which  may  be  termed  erythema 
multiforme,  consisting  in  a  tendency  to  vascular  dilatation 
of  different  degrees  and  distribution,  and  escape  of  serum 
into  the  tissues  (urticaria).  It  appears  that  different  brands 
of  serum  tend  to  produce  different  types  of  eruption. 

1.  Erythema,  or  simple  localized  hypersemia,  is  generally 

1  Lancet,  1899,  i.  891. 

2  Galitsis,    These  de  Paris,    quoted   in  Journ.  de   Med.  et  Chir. 
Pratiques,  Sept.  25,   1903,  p.  692,  states  that  some  eruptions  occur- 
ring in  diphtheria  are  due   to   infection  with   a   special  organism, 
Diplococous  hemipholus,  and  are  wrongly  attributed  to  the  serum. 

3  Brit.  Med.  Journ.,  1902,  i.  386. 

4  Op.  cit. 
6  Op.  cit. 


SERUM    RASHES  129 

regarded  as  the  commonest  form  of  rash.  It  may  take  the 
shape  of  a  slight  blush,  either  at  the  point  of  injection  or 
elsewhere,  or  may  consist  of  slightly  raised  circinate  patches, 
which  may  coalesce  to  form  gyrate  patterns.  Favourite 
seats  of  this  variety  are  the  extensor  surface  of  the  limbs. 
Out  of  112  cases  of  rash  noted  by  Stanley,  58  were  simple 
erythema.  Its  average  date  of  appearance  after  the  injec- 
tion was  the  twelfth  day,  varying  from  the  fourth  to  the 
twenty-ninth.  It  may  be  combined  with  urticaria  (15 
cases). 

2.  The  scarlatiniform  rash  is  a  more  pronounced  form 
of  the  erythematous ;  it  is  more  intense  and  becomes 
widely  geneialized.  Stanley  noted  this  variety  in  6  cases 
out  of  112.  It  is  often  followed  by  desquamation.  Leiner l 
states  that  this  form  of  eruption  tends  to  come  out  within 
the  first  five  days  after  injection — an  earlier  period  than 
that  of  most  of  the  other  varieties ;  that  it  starts  from  the 
point  of  injection  ;  that  it  is  followed  by  peeling  ;  that  it  is 
contagious,  and  that  it  seems  to  protect  against  infection 
with  scarlatina.  The  infection  is  difficult  to  eradicate 
from  a  ward  in  which  cases  have  occurred.  He  concludes 
that  it  is  true  scarlatina,  and  compares  it  with  the  surgical 
variety  of  this  disease.  It  is  very  possible  that  the  cases 
observed  by  Leiner  were  of  this  nature,  and  there  is  no 
doubt  that  the  diagnosis  between  a  serum  rash  and  an 
attack  of  true  scarlet  fever  must  be  difficult ;  but  there  is 
no  reason  to  suppose  that  all  cases  of  scarlatiniform  rash 
after  the  administration  of  antitoxin  are  of  this  character. 
The  coexistence  of  diphtheria  and  scarlatina  is,  however, 
not  very  infrequent. 

•'».  Morbilliform  eruptions  formed  less  than  3  per 
cent,  of  Stanley's  cases.  They  may  be  accompanied  by 
swelling  of  the  face,  conjunctivitis,  and  lachrymation,  so  as 
3xactly  to  resemble  measles.  Even  pyrexia  may  occur. 
)istinguishing  points  from  true  measles  are  that  the  rash 
Jomes  out  first  on  the  limbs,  instead  of  on  the  face  and 

1   Jficn.  klin.   Woch.,  1902,  No.  43. 
J 


130       SERUMS,    VACCINES,    AND    TOXINS 

behind  the  ears ;  that  gyrate  patterns  are  met  with  ;  and 
that  there  is  no  accompanying  bronchitis  (Villy). 

4.  Urticarial  eruptions  are  common.  They  occurred 
in  30  of  Stanley's  112  cases.  They  are  met  with  at  an 
earlier  period  after  injection  than  the  erythemata — from 
the  fourth  to  the  nineteenth  day  (average,  ninth,  Stanley). 
The  urticaria  may  be  quite  transient,  or  may  last  several 
days.  The  itching  is  sometimes  very  severe.  A  local 
urticaria  round  the  site  of  injection  may  be  seen. 

Pains  in  the  joints,  often  accompanied  by  swelling, 
erythema,  and  pyrexia,  are  another  inconvenience  which 
may  arise  after  injections  of  serum.  They  are  not  usually 
severe,  but  Taillens T  records  two  cases  in  which  they  were 
accompanied  by  high  fever  and  a  rash ;  in  one  of  his 
cases  the  pains  were  so  intense  that  the  child  could  not 
move  at  all,  or  bear  the  weight  of  the  bed-clothes  to  rest 
on  her.  Villy  noted  joint-pains  in  6-5  per  cent,  of  his 
cases. 

Successive  outbreaks  of  cutaneous  eruptions  or  attacks  of 
joint-pains  often  correspond  with  successive  administrations 
of  serum. 

Albuminuria  may  follow  the  use  of  antitoxin,  but  is 
not  of  any  serious  import.  Actual  nephritis  is  said  to  be 
rather  diminished  than  increased  by  the  use  of  this  remedy, 
and  certainly  existing  albuminuria  does  not  contraindicate 
the  use  of  antitoxin.  Suppression  of  urine  is  also  more 
rarely  seen  in  these  days  (Villy).  A  rise  of  temperature  as 
a  result  of  the  antitoxin  was  observed  by  this  writer  in 
19-8  per  cent,  of  his  cases. 

An  interesting  case  illustrating  the  effects  of  idiosyn- 
crasy in  relation  to  antitoxic  serum  is  reported  by  Heckles.2 
He  administered  an  injection  of  4,000  units  of  antitoxin  to 
a  woman  who  was  suffering  from  faucial  diphtheria.  A  few 
days  later,  when  she  appeared  to  be  convalescent,  a  severe 
urticaria  developed,  and  shortly  afterwards  she  was  seized 

1  Jievue  Med.  de  la  Suisse  Romande,  July  20,  1903,  p.  463. 

2  Quarterly  Med.  Journ.,  Feb.,  1903. 


SERUM    ANAPHYLAXIS  131 

with  a  sudden  attack  of  prtecordial  pain  and  dyspnoea,  with 
marked  lividity  of  the  face.  In  the  next  few  days  nine 
successive  attacks  of  this  nature  were  experienced,  but  in 
the  end  the  patient  recovered  satisfactorily.  It  was  subse- 
quently learnt  that  two  years  previously  she  had  received 
an  injection  of  antitoxin  for  diphtheria,  and  that  she  had 
on  that  occasion  also  suffered  from  attacks  of  dyspnoea  and 
cyanosis ;  and  the  question  naturally  arises  as  to  whether 
these  symptoms,  though  late  in  appearing,  can  be  attributed 
to  anaphylaxis. 

Borchman  l  states  that  antitoxic  serum  produces  less  ill 
effects  if  it  is  warmed  to  58°  C.  before  it  is  injected.  This 
has  only  a  slight  effect  in  diminishing  its  potency.  He 
quotes  his  experience  in  578  cases;  in  193  of  these  the 
remedy  was  given  in  the  ordinary  way,  cold,  and  among 
these  there  were  22*7  per  cent,  of  rashes.  On  the  other 
hand,  among  385  patients  who  received  the  warm  serum, 
only  16 -3  per  cent,  developed  these  troubles.  Courmont2 
reports  that  no  rashes  or  anaphylaxis  follow  the  intravenous 
injection  of  serum.  Rolleston  regards  the  occurrence  of 
serum-rashes  as  of  good  prognostic  import. 

Antitoxin  in  conjunct! val  diphtheria.  —  Anti- 
toxin has  proved  of  the  greatest  service  in  diphtherial 
infection  of  the  conjunctiva.  Emmett  Holt 3  states  that 
without  it  total  destruction  of  the  eye  generally  results, 
whereas  with  its  aid  good  results  may  be  obtained.  He 
administers  2,400  units  as  a  dose.  Stevenson1  also  bears 
testimony  to  the  value  of  the  remedy,  as  the  result  of  a 
study  of  43  cases  ;  he  advises  the  local  use,  along  with  the 
antitoxin,  of  a  lotion  of  perchloride  of  mercury  (1  :  5,000). 
The  diphtherial  nature  of  the  affection  must  be  established 

1  Diets/caya  Meditsina,  1900,  v.,  No.  3.      (Abstr.  in  Pediatrics,  1900, 
vol.  x.,  p.  316.) 

2  Sot.  Med.  des  Hop.,  1905,  p.  504. 

3  Pediatrics,  May,  1902. 

.  *  Brit.  Med.  Joitrn.,  1902,  i.  720.  Cf.  Strzeminski,  Secueil  d'Op/t- 
talmol.,  Oct.,  1905. 


132       SERUMS,   VACCINES,    AND   TOXINS 

by  bacteriological  examination,  including  inoculation  ex- 
periments, the  morphological  resemblance  between  B. 
diphtheria*,  and  B.  xerosis  being  a  fruitful  source  of 
error. 

Post-scarlatinal  ear-disease.— On  the  other  hand, 

curiously  enough,  in  some  cases  of  middle-ear  disease  follow- 
ing scarlatina,  in  which  diphtheria  twicilli  appear  to  be  the 
pathogenic  organisms,  antitoxin  is  said  to  act  neither  as  a 
prophylactic  nor  as  a  curative  agent,  although  the  patients 
seem  to  obtain  immunity  to  faucial  infection  by  the 
bacilli.1 

Cancmm  oris. — Some  cases  of  noma,  or  cancrum  oris, 
are  due  to  the  B.  diphtheric-  and  should  be  treated  with 
antitoxin.  Telford2  records  a  successful  case. 

Diphtheria  as  a  complication  of  other  diseases.— 

Diphtheria  is  liable  to  occur  as  a  complication  of  scarlet 
fever  and  of  measles.  In  the  former  malady  the  supervention 
of  diphtheria  constitutes  a  very  grave  condition,  the  mor- 
tality being  very  high.  In  measles,  also,  infection  with 
diphtheria  is  very  likely  to  occur.  It  has  therefore  been 
suggested  that  prophylactic  injections  of  antitoxin  should 
be  given  as  routine  treatment  in  both  these  diseases.  If 
many  cases  of  such  superinfection  have  occurred  in  a 
scarlet-fever  ward,  then  such  treatment  would  certainly  be 
advisable.  Heubner 3  states  that  a  larger  dose  of  the 
serum  is  needed  to  produce  immunity  in  cases  of  measles 
than  under  other  conditions  (twice  the  amount),  and  that 
the  duration  of  the  protection  is  also  shorter.  Bichardiere  ' 
records  that  in  the  first  four  months  of  the  year  1901  two 
to  four  cases  of  diphtheria  used  to  occur  each  month  in  the 
measles-ward  of  a  hospital.  After  this  time  all  the  children 
as  they  came  into  the  ward  were  injected  with  antitoxin, 
and  no  more  cases  of  diphtheria  occurred. 

1  Duncan  Forbes,  Journ.  of  Pat  hoi.  and  Barter.,  1903,  viiL  448. 
-  Med.  Chro».,  1906,  p.  221. 

3  Quoted  by  Netter,  Bull,  de  TAcad.  de  Med.,  Paris,  March  18,  1902. 

4  Ibid. 


NON-SPECIFIC   USE    OF   ANTITOXIN      133 

Nasal  diphtheria.1 — The  ordinary  acute  faucial  diph- 
theria may  spread  to  the  nose,  and  such  cases  show  a 
very  high  rate  of  mortality.  Large  doses  of  antitoxin  are 
called  for  by  way  of  treatment.  There  is  also  a  chronic 
nasal  inflammation  associated  with  the  formation  of  mem- 
brane (membranous  rhinitis),  which  affects  the  nose,  and  in 
which  virulent  diphtheria  bacilli  are  found.  The  patients 
do  not  suffer  from  the  toxic  symptoms  characteristic  of 
diphtheria,  nor  do  they  exhibit,  as  a  rule,  any  distinct  signs 
of  ill  health ;  but  the  discharge  from  the  nose  is  capable 
of  conveying  the  infection  to  others.  Indeed,  it  is  probable 
that  many  epidemics  of  diphtheria,  the  origin  of  which  has 
been  difficult  to  understand,  might  be  traced  to  such  chronic 
nasal  disease,  that  may  pass  as  an  ordinary  "  cold  in  the 
head."  Antitoxin  often  acts  successfully  in  these  cases; 
at  other  times  antibacterial  serum  (p.  134)  is  useful. 

Diphtherial  antitoxin  in  other  diseases.— Various 

writers  have  detailed  their  experience  with  antitoxin  in 
diseases  other  than  diphtheria.  Thus  Talamon  and  Gay 
have  used  it  in  pneumonia ;  Paton  recommends  it  for 
all  septic  conditions,  and  thinks  it  has  a  definite  influ- 
ence on  inflammatory  tissue  ;  Schapiro  and  Tsvietaieff,  and 
Mastri  and  Tomaselli  have  tried  it  in  erysipelas ;  and  Ko- 
narzsherski  believes  that  it  will  cure  whooping-cough.  Del 
Monaco  believes  it  to  be  efficacious  in  aphthous  stomatitis, 
Sizemski  in  ozsena,  and  Gillett  used  it  with  benefit  in  a  case 
of  asthma — not  a  microbial  disease.  It  is  difficult  to  take 

1  In  this  connection  we  may  note  that  Mygind  (Journal  of  Laryn- 
yoloyy,  Aug.,  1898)  made  use  of  injections  of  diphtherial  antitoxin  in 
lo  cases  of  oztena.  He  found  that  the  injections  produced  congestion 
of  the  mucosa  of  the  nose  and  subsequent  formation  of  crusts,  while 
the  fetid  odour  disappeared.  It  does  not  seem  to  he  suggested  that 
the  B.  diphtheria;  is  the  cause  of  oza3na,  the  nature  of  which  is  not 
well  understood.  Mygind's  experience  with  antitoxin  is  analogous 
to  that  of  other  observers  in  the  different  maladies  alluded  to  in  the 
text,  in  which  it  is  difficult  to  believe  that  the  good  results  seen 
were  in  reality  due  to  the  antitoxin.  Our  present  knowledge  of  the 
action  of  serums  is,  however,  too  small  to  enable  us  to  pronounce  with 
any  degree  of  confidence  as  to  what  they  can  or  cannot  do. 


134       SERUMS,    VACCINES,    AND   TOXINS 

these  results  seriously,  since  the  most  definitely  established 
fact  at  present  with  regard  to  serums  is  their  specific 
nature,  i.e.  the  power  possessed  by  each  of  counteracting 
the  poisons  or  killing  the  bacteria  of  that  disease  alone 
for  which  it  is  manufactured.  It  has,  indeed,  been  sug- 
gested that  diphtherial  antitoxin  may  act  as  a  stimulant 
to  the  production  of  leucocytes  generally,  and  so  may  be 
useful  in  other  diseases  in  which  leucocytosis  is  beneficial, 
much  in  the  same  way  as  cinnamic  acid  is  said  to  act  in 
tuberculosis.  Thus  R.  French  has  observed  a  gradual  but 
steady  rise  in  the  tuberculo-opsonic  index  following  the 
administration  of  3,000  units  in  a  case  of  tuberculous 
disease  of  the  hip.  Bradshaw l  records  a  distinct  rise  in 
the  tuberculo-opsonic  index  shortly  after  an  injection  of 
anti-diphtherial  serum,  followed,  however,  by  a  marked 
fall,  from  one  to  three  months  later.  In  spite  of  these 
observations,  the  probabilities  point  at  present  rather  to 
the  supposed  benefits  of  antitoxin  in  other  diseases  being 
due  to  fallacies  of  observation,  which  are  difficult  to  avoid 
in  studying  the  action  of  any  remedy. 

ANTIBACTERIAL   SERUM 

Antitoxic  serum,  as  already  explained,  does  not  tend 
to  kill  the  bacilli  which  cause  diphtheria.  They  will 
grow  readily  in  the  fluid  itself,  and  continue  to  exist  in  a 
virulent  form  in  the  throats  of  persons  who  have  been 
injected  with  antitoxin.  Wasserniann  -  claims  to  have  suc- 
ceeded in  the  production  of  a  serum  which  is  bactericidal. 
He  prepares  a  fluid  somewhat  analogous  to  Koch's  "  new 
tuberculin,"  by  pounding  up  the  bacilli  and  extracting 
them  with  ethylene-diamine,  20  c.c.  of  this  solvent  being 
added  to  1  grm.  of  pulverized  bacilli.  The  mixture  is 
well  shaken  in  a  special  apparatus,  and  is  then  sub- 
mitted to  the  centrifuge.  The  supernatant  fluid  is  of  a 
yellow  colour,  and  contains  the  intracellular  toxins  of 

1  Lancet,  1906,  i.  1387. 

2  Deut.  med.  JToch.,  Oct.  30,  1902. 


VACCINE   TREATMENT   OF    DIPHTHERIA  135 

the  bacilli.  It  is  capable  of  killing  rabbits  when  injected 
into  them.  If,  however,  the  toxin  is  mixed  with  a  pro- 
portion of  antitoxin  and  repeatedly  injected  into  these 
animals,  the  serum  obtained  from  them  is  strongly  ag- 
glutinative of  diphtheria  bacilli.  Wassermann  thinks  that 
this  serum  will  afford  a  means  of  distinguishing  B.  dipk- 
therice  from  pseudo-diphtheria  bacilli,  and  that  it  may 
possibly  have  curative  properties. 

Concetti l  writes  in  favour  of  the  use  of  antibacterial 
serum  as  an  adjunct  to  antitoxin,  and  as  a  local  applica- 
tion to  the  throat  in  the  form  of  lozenges.  A  "bivalent" 
(antitoxic  and  antibacterial)  serum  may  also  be  used  pro- 
phylactically,  as  well  as  for  irrigation  of  the  nostrils  to  avoid 
spread  of  infection  to  the  nose ;  for  local  application  to  the 
trachea  after  tracheotomy  (2-5  c.c.  every  three  hours) ;  and 
in  conjunctival  diphtheria  (Bandi). "  Dopter3  advises  the 
local  use  of  antitoxic  serum  in  the  form  of  lozenges  ;  but  this 
serum  is  theoretically  inferior  to  the  bivalent  serum.  He 
also  uses  insufflations  of  powdered  dry  serum  for  nasal 
diphtheria,  and  finds  this  procedure  of  some  value,  but  less 
so  than  in  faucial  cases. 

VACCINE  TREATMENT 

Possessing,  as  we  do,  in  antitoxic  serum  a  remedy  at  once 
so  potent  and  so  reliable,  and  one,  moreover,  which  has  the 
overwhelming  advantage  of  being  available  at  a  moment's 
notice,  it  is  not  surprising  to  find  that  diphtheria  vaccine  has 
not  been  employed  therapeutically  to  any  large  extent.  At 
the  same  time  vaccine  treatment  is  of  distinct  value  in 
those  infections  which  become  chronic,  and  in  which  the  re- 
sponsible organism  remains  domiciled  in  the  throat  or  nose 
for  prolonged  periods  after  the  acute  clinical  symptoms 
have  been  entirely  removed  by  the  employment  of  antitoxin 
("  carriers  ").  In  such  cases  a  vaccine  should  be  prepared 

1  Riv.  di  din.  Pediatr.,  1905,  No.  6. 

2  11  Policlin.,  July,  1906. 

8  Gaz.  des  Hop.,  1905,  p.  459. 


136       SERUMS,    VACCINES,    AND    TOXINS 

from  that  strain  of  B.  diphtheria  actually  infecting  the 
patient,  the  bodies  of  the  bacilli  carefully  washed  free  from 
toxin,  the  vaccine  then  standardized,  and  administered  in 
doses  of  5  to  10  millions  at  intervals  of  three  to  five  or 
seven  days.  In  our  experience  one  to  two  injections  are 
usually  sufficient  to  ensure  the  disappearance  of  the  bacilli 
from  the  local  site  of  infection.  Hewlett l  uses  for  the  same 
purpose  endotoxin  obtained  from  the  diphtheria  bacillus  by 
grinding  at  the  temperature  of  liquid  air  in  doses  of  0'5  mg. 

DIAGNOSIS 

Bacteriological  examination  of  the  membranous  exuda- 
tion with  the  demonstration  of  the  presence  of  the  diphtheria 
bacillus  is  the  only  reliable  method  of  diagnosis,  although 
many  other  methods  have  from  time  to  time  been  advocated. 
Schich  2  has  suggested  the  subcutaneous  injection  of  small 
doses  of  diphtheria  toxin  as  a  test  for  the  existence  of  the 
infection,  stating  that  susceptible  individuals  exhibit  red- 
ness at  the  seat  of  inoculation,  which  appears  in  from 
twenty-four  to  forty-eight  hours,  lasts  from  seven  to  ten 
days,  and  as  it  fades  is  followed  by  scaling  of  the  skin  and 
a  persistent  brownish  pigmentation. 

Agglutination.  —  The  agglutination  of  diphtheria 
bacilli  is  not  very  easily  obtained,  as  the  bacteria  naturally 
occur  in  masses,  closely  adherent  together.  Lubowski 3 
obtained  the  bacilli  in  a  state  of  division  by  shaking  up 
an  emulsion  of  them  with  small  glass  balls,  and  diluting 
the  resulting  fluid  with  a  10  per  cent,  solution  of  glycerin. 
The  reaction  is  of  no  practical  value  in  the  diagnosis  of 
diphtheria. 

CONCLUSION'S 

1.  Prophylaxis. — Diphtherial  antitoxin  has  a  definite 
power  of  preventing  the  onset  of  diphtheria.  The  prophy- 
lactic dose  should  be  500  units.  Antitoxin  should  be  used 

1  Lancet.  1915,  i.  '27.'). 

•  Bonton  Med.  and  Sury.  Journ.,  1914. 

s  Zeitschr.f.  Hygiene,  1900,  Ed.  xxxv. 


ANTITOXIN   IN  DIPHTHERIA  137 

with  this  object  in  institutions  where  children  are  congre- 
gated together,  if  there  is  any  tendency  to  an  endemic 
prevalence  of  the  disease  in  the  institution.  In  other 
cases,  if  the  children  can  be  kept  under  close  observation 
these  protective  doses  are  not  absolutely  necessary,  as  the 
prompt  administration  of  the  serum  on  the  first  appearance 
of  the  disease  is  an  almost  absolute  safeguard  against  a 
fatal  issue.  If  "  swabs  "  can  be  taken  from  the  throats  of 
children  exposed  to  infection,  and  examined  for  bacilli,  the 
prophylactic  doses  of  serum  need  only  be  given  to  such  as 
exhibit  the  organisms  in  their  fauces. 

2.  Treatment. — The  curative  effects   of   the  serum  are 
well  established.     The  remedy  should  be  given  as  early  as 
possible  in  the  course  of  the  disease,  as  the  mortality  is 
progressively  greater  according  as  the  serum   is  adminis- 
tered on  later  and  later  days.     Therefore,  if  the   clinical 
appearances  are  those  of  diphtheria,  it  is  advisable  to  secure 
material  for  bacteriological  examination,  but  to  administer 
antitoxin   without   tvaiting  for   the    bacteriological   report. 
The  initial   dose   for   an    ordinary   case   need   not   exceed 
4,000  units.      In  severer  cases  much  larger  doses  may  be 
given.     The  dose  may  be  repeated  as  often  as  necessary 
at    intervals  of   four,  six,    twelve,    or   twenty-four   hours. 
Serum  should  be  re-administered  in  case  of  relapse,  but 
true  relapse   must  be   carefully  distinguished  from  simple 
angina  redux. 

3.  Method  of  administration. — In    ordinary  cases  sub- 
cutaneous or  intramuscular  injection  of  the  serum  is  advis- 
able.    In  very  severe  cases  it  may  be  given  intravenously 
(warmed),  in  order  to  get  the  patient   under  its  influence 
as  soon   as  possible.     The  efficacy  of  the  use  of  antitoxin 
by  the  mouth  or  rectum  needs  further  elucidation.     In  the 
present  state  of  our  knowledge  it  is  hardly  justifiable  to 
make  use  of  this  method  of  administration. 

4.  Ordinary  measures  of  prophylaxis  (isolation,  etc.)  and 
of  treatment  should   not  be  omitted  because  antitoxin  is 
used. 


CHAPTER  VJ 
TETANUS 

Causal  Organism. — The  micro-organism  (B.  tetani)  which 
is  the  cause  of  tetanus  was  discovered  by  Nicolaier  in  1884, 
and  was  first  isolated  in  pure  culture  by  Kitasato  in  1890. 
The  bacillus,  in  the  form  of  spores,  is  widely  distributed 
in  nature,  being  commonly  found  in  cultivated  (manured) 
soils.  Joseph l  and  Lukas 2  record  its  frequent  presence  in 
the  intestinal  contents  of  horses  and  cattle. 

Entering  the  body  by  a  wound  in  the  skin  or  mucous 
membrane,3  the  bacilli  do  not  become  generalized  by  means 
of  the  blood-stream,4  but  remain  localized  at  the  point  of 
infection,  where  they  form  their  toxins.  These  are  taken 
\ip  by  the  peripheral  nerves,  and  are  carried  along  the 
axis-cylinders  to  the  central  nervous  system.  Exactly  the 
same  mode  of  conveyance  seems  to  hold  good  in  the  case 

1  Zeitsehr.f.  Infektkr.  u.  Hyg.  der  Haustier,  1910,  vii.  96. 

2  Zeitschr.f.  Tiermed.,  1914,  xviii.  17. 

*  Commercial  gelatin  is  very  liable  to  contain  the  spores  of  tetanus, 
and  a  number  of  cases  have  been  recorded  in  which  the  disease  occurred 
after  gelatin  injections  made  for  the  treatment  of  aneurysm.      An 
outbreak  also  occurred  in  the  United  States,  due  to  contamination  of 
diphtherial  antitoxin  with  the  toxins  of  tetanus.    Cases  have  occurred 
after  vaccination,  either  due  to  the  presence  of  the  organisms  or  their 
spores   in   vaccine-lymph,  or  to   subsequent  inoculation  of  the  vac- 
cination lesions  from  accidental  sources.     Vaccination  wounds  may 
perhaps  afford  a  specially  favourable   nidus  for   the  organisms,  as 
they  form  an  ulcerated  surface  beneath  a  scab.     Undeserved  discredit 
was  thrown   upon  Haffkine's  method  of  antiplague  vaccination  by 
some  cases  of  tetanus  arising  from  neglect  of  antiseptic  precautions 
in  the  use  of  his  prophylactic. 

*  Lambert  (Mod.  News,  1900,  July,  p.  12)  states  that  the  bacilli 
may  wander  into  the  general  circulation. 

138 


PATHOLOGY  OF    TETANUS  139 

of  the  poison  of  hydrophobia,  and  it  seems  that  there 
must  be  a  continual  streaming  of  the  protoplasm  of  the 
nerve-fibrils  towards  the  cells  from  which  they  are  prolonga- 
tions. Resection  of  a  portion  of  a  nerve  may  prevent  the 
onset  of  tetanus  in  animals,  if  only  a  very  small  dose  of 
the  toxins  has  been  administered.  Part  of  the  poison  is 
absorbed  into  the  lymph  and  blood,  and,  reaching  the  general 
circulation,  may  pass  directly  to  the  ganglion  cells  of  the 
cord,  or  indirectly  by  means  of  peripheral  nerves.1  Meyer 
and  Ransom,3  as  the  result  of  many  ingenious  experiments, 
consider  that  it  is  only  by  the  peripheral  nerves  that  the 
poison  can  reach  the  spinal  cord  or  brain.  Poison  circu- 
lating in  the  blood  is  taken  up  by  the  nerve-endings,  and 
so  passed  on  to  the  central  portions  of  the  nervous  system, 
but  it  does  not  penetrate  directly  into  the  latter  from  the 
lymph.  They  thus  explain  the  greater  part  of  the  incuba- 
tion period  met  with  in  poisoning  by  tetanus  toxins.  They 
point  out  that  the  incubation  is  longer  in  direct  proportion 
to  the  size  of  the  animal  and  the  consequent  length  of 
the  nerves.  Thus  a  mouse  exhibits  symptoms  in  eight  to 
twelve  hours,  a  guineapig  in  thirteen  to  eighteen,  a  rabbit 
in  eighteen  to  thirty-six,  while  in  man  four  days  is  the 
usual  period,  and  in  the  horse  five  days.  If  an  animal 
is  injected  with  the  poison  in  the  nerve  of  a  hinder  limb, 
the  spread  of  the  poison  to  the  important  centres  in  the 
medulla  can  be  prevented  by  section  of  the  spinal  cord. 
In  this,  as  in  the  peripheral  nerves,  there  appears  to  be 
a  centripetal  movement  of  protoplasm. 

In  cases  of  tetanus  in  man,  the  incubation  period  is 
very  variable.  Symptoms  may  appear  in  four  or  five  days? 
although  an  incubation  period  so  short  as  twenty-four 
hours  has  been  recorded  by  Elver,3  or  they  may  be  delayed 
for  months.  The  more  rapid  the  onset,  the  more  acute  are 

1  Permin,  Commun.  de  Plnst.  Serother.  de  FlZtat  Danois,  1913,  viii. 

2 Arch. f.  exper.  Pathol.  u.  Pharmakol,  1903,  Bd.  xlix.,  Heft  6,  p.  369. 
Cf.  Marie  and  Morax,  Ann.  de  VInst.  Pasteur,  1902,  xvi.  818;  1903, 
xvii.  335.  *Deut.  med.  Woch.,  1910,  p.  961. 


140       SERUMS,   VACCINES,    AND   TOXINS 

the  symptoms  and  the  more  grave  the  prognosis.  That 
spores  of  tetanus  bacilli  washed  free  from  toxin  and  ex- 
perimentally injected  into  healthy  animals1  may  fail  to 
germinate,  or  may  circulate  harmlessly  until  some  injury 
is  inflicted,  when  they  multiply  at  the  point  of  lesion  and 
give  rise  to  tetanus,  has  been  shown  by  Canford  ,-  and  the 
long  latency  of  some  cases  in  the  human  subject  may  be 
explained  on  similar  grounds. 

Toxins  of  the  tetanus  bacillus.  —  The  toxins  of 

the  bacillus  may  be  obtained  by  growing  the  organisms  in 
an  atmosphere  of  hydrogen  in  broth  from  which  all  oxygen 
has  been  expelled  by  causing  hydrogen  gas  to  bubble 
through  it.  It  is  usual  to  add  to  the  nutrient  broth  some 
reducing  agent  such  as  glucose,  formate  or  sulphindigotate 
of  soda,  and  then  to  tint  the  liquid  with  methylene  blue  to 
act  as  an  indicator,  the  blue  colour  disappearing  when  the 
last  trace  of  oxygen  has  been  removed  from  the  medium. 
Marie  and  Morax  3  state  that  a  potent  poison  can  be  pre- 
pared by  cultivating  the  bacilli  in  association  with  Bacillus 
subtUis  in  the  presence  of  air. 

The  fluid  obtained  after  about  eight  to  ten  days'  growth 
is  filtered  through  a  porcelain  filter,  and  the  filtrate  is  ready 
for  use.  The  poison  gradually  loses  strength  on  keeping, 
probably  owing  to  the  formation  of  toxones  similar  to  those 
described  in  connection  with  diphtheria  (p.  103).  Tetanus 
toxin  is  not  destroyed  by  heating  to  135°  C.  for  ten  minutes, 
but  its  action  is  slightly  retarded  j  its  potency  is  rapidly 
destroyed  by  sunlight.  If  the  albuminous  constituents  of 
the  culture-fluid  are  precipitated  by  alcohol  or  other  reagents, 
the  toxin  is  found  in  the  precipitate ;  but  it  is  probably  not 
of  an  albuminous  nature  itself.  Dean  *  concludes  as  follows 
with  regard  to  it :  "  Tetanus  toxin  has  thus  many  points 

1  Centralbl.f.  Bakl.,  I.  Orig.,  1907,  xlv.  295. 
*  Ibid.,  1908,  xlviii. 
»  Ann.  de  flnst.  Pasteur,  1902,  xvi.  418. 

4  Art.  "Tetanus"  in   '•  Quain's  Dictionary  of  Medicine,"  edited 
by  Montague  Murray,  1902,  p.  1688. 


TOXINS   OF    TETANUS  141 

of  resemblance  to  the  soluble  ferments;  it  is  difficult  to 
dialyse,  is  soluble  in  water,  is  precipitated  by  alcohol  and 
t/ends  to  adhere  to  precipitates,  is  modified  or  destroyed  by 
the  action  of  air,  sunlight,  and  comparatively  low  tem- 
peratures, and  requires  an  incubation  period  for  its  action." 

The  mixed  poison,  as  obtained  from  cultures,  is  almost 
certainly  very  complex  in  character.  Tizzoni  and  Collina  1 
state  that  it  contains  two  toxins,  one  of  which  acts 
specially  if  it  is  administered  subcutaneously,  and  produces 
convulsions,  while  the  second  becomes  prominent  in  case 
of  intravenous  injection,  giving  rise  to  local  tonic  spasm. 
Ehrlich  2  has  shown  that  there  is  also  present  a  substance 
which  produces  hsemolysis  (tetanolysin),  and  that  an  anti- 
lysin  which  neutralizes  this  is  found  in  tetanus  antitoxin.  - 

Tetanus  toxin,  or  tetanine,  as  it  is  called  by  French 
writers — using  the  word  to  apply  to  the  poisons  collec- 
tively— has  a  great  affinity  for  the  nervous  system.  If 
an  animal  has  died  of  tetanus,  the  nerves  leading  from 
the  seat  of  infection,  and  also  the  brain  and  spinal  cord, 
contain  the  poison.  The  affinity  of  the  brain  tissue  for  the 
toxin  has  also  been  shown  in  another  way  by  Wassermann 
and  Takaki,3  who  found  that  if  they  made  an  emulsion 
of  brain-substance,  and  mixed  this  with  the  toxins  before 
injection  into  animals,  no  ill  effects  were  produced.  A 
protective  influence  was  exercised  even  if  the  emulsion 
was  injected  at  a  different  point  from  the  toxin,  without 
previous  mixture.  Cerebral  substance  seems  thus  to  act 
as  an  antitoxin  to  the  poison  :  in  other  words,  the  toxin 
has  the  power  of  combining  with  the  side-chains  of  the 
cerebral  cells ;  when,  therefoi'e,  these  cells  are  injected 
into  another  animal,  they  are  capable  of  uniting  with  the 
free  poison  and  sp  preventing  it  from  attacking  the  living 
tissues  of  the  animal. 

The  pathological  effects  of  tetanus  toxin  are  seen  in  the 

1  Gaz.  degli  Ospedali,  1901,  No.  138. 

2  Quoted  by  Dean,  loc.  c\t. 

3  Berlin,  kiln.  JFoch.,  1898,  No.  1. 


142       SERUMS,   VACCINES,   AND   TOXINS 

cells  of  the  nervous  system,  and  consist  in  swelling  of  the 
chromatic  bodies  and  cell-body,  followed  by  progressive 
chromatolysis.  These  lesions  are  of  rather  irregular  dis- 
tribution, being  more  uniform  and  intense  in  the  brain 
than  in  the  cord  ;  and,  with  the  possible  exception  of  the 
early  stages  of  the  process,  the  changes  are  not  specific  of 
the  disease. 

The  toxin  exists  in  other  organs  besides  the  nervous 
system,  and  may  be  extracted  from  them  by  glycerin.1 
The  peripheral  nerves  contain  it,  but  have  not  the  same 
neutralizing  action  as  is  possessed  by  the  brain  and  spinal 
cord.  The  occasional  appearance  of  a  peripheral  neuritis 
in  patients  who  recover  from  tetanus  has  been  attributed  to 
a  toxone  analogous  to  that  of  diphtheria.2 

TETANUS   ANTITOXIN 

Preparation  Of  antitoxin. — For  the  practical  pre- 
paration of  antitoxin  for  tetanus,  horses  are  used.  These 
animals  are  very  sensitive  to  the  toxins  of  the  disease, 
and  great  care  is  necessary  in  the  process  of  immuniza- 
tion. At  the  beginning  of  the  treatment,  use  is  made  of 
a  toxin  which  has  been  attenuated  by  means  either  of  some 
chemical  agency  (iodine  trichloride  is  used  by  Behring)  or  by 
mixture  with  antitoxin,  which  is  injected  subcutaneously 
or  intramuscularly  in  increasing  doses  at  intervals  of  five 
to  ten  days.  After  the  blood  of  the  animal  has  been 
found  to  contain  a  considerable  amount  of  antitoxin,  as  a 
result  of  these  injections,  the  undiluted  toxin  may  be 
administered.  The  method  of  procedure  is  the  same  as 
that  already  described  in  the  case  of  diphtheria. 

Standardization  Of  antitoxin. — A  method  of  stand- 
ardizing tetanus  antitoxin  similar  to  that  in  use  for  anti- 
diphtherial  serum  has  been  introduced  by  Behring.  A  test 
toxin  is  prepared  of  such  a  strength  that  O01  c.c.  will  kill  a 
guineapig  of  500  grm.  in  about  four  days.  This  amount 

1  Waring,  Proc.  Path.  Soc.  Lond. ;  Brit.  Med.  Jotirn.,  1902,  i.  965. 

2  Griinberger,  Wien.  klin.  IFoch.,  1904,  p.  737. 


TETANUS   ANTITOXIN  143 

of  toxin  is  neutralized  by  ToW  of  a  unit  of  antitoxin.  In 
other  words,  one  unit  of  antitoxin  will  protect  a  guineapig 
against  1,000  minimal  lethal  doses  of  toxin. 

According  to  Roux's  method  of  standardization,  the 
value  of  the  antitoxin  is  expressed  according  to  the 
number  of  guineapigs  (calculated  in  grammes)  which  1  c.c. 
of  the  serum  will  protect  from  a  minimal  fatal  dose  (for 
that  number  of  guineapigs).  Thus,  if  1  c.c.  of  a  certain 
serum  will  protect  100  guineapigs,  each  weighing  500 
grm.,  against  the  minimal  amount  of  toxin  which  would 
otherwise  kill  them  in  four  days,  this  quantity  of  serum 
is  said  to  contain  50,000  (100  x  500).  This  would  be  a 
very  weak  serum  for  use,  1,000,000  such  units  per  cubic 
centimetre  being  an  average  strength. 

Rosenau  and  Anderson l  take  as  a  unit  of  antitoxin  ten 
times  the  least  quantity  of  antitoxin  which  will  keep  a 
guineapig  (of  350  grm.)  alive  for  ninety-six  hours  after 
injection,  of  an  official  toxic  unit.  This  latter  unit  is  the 
equivalent  of  100  minimum  lethal  doses. 

Unfortunately  no  antitetanic  unit  has  gained  universal 
acceptance  in  the  description  of  the  various  serums  on 
the  market,  the  dose  being  generally  calculated  in  cubic 
centimetres  of  serum,  without  any  statement  of  the  number 
of  units  contained.  Hence  cases  recorded  as  treated  with 
antitoxin  have  hitherto  had  very  little  value,  owing  to  the 
impossibility  of  knowing  how  many  units  of  antitoxin 
were  really  used.  There  is,  however,  at  the  present  time 
a  growing  tendency,  in  all  English-speaking  countries,  to 
adopt  the  U.S.A.  antitoxic  unit ;  and  MacConkey,2  who 
has  recently  compared  the  various  units,  states  that  the 
German  (Behring)  unit  is  equivalent  to  about  40  U.S.A. 
units;  1,GOO  Italian  (Tizzoni)  units  are  equivalent  to  one 
U.S.A.  unit ;  2  French  (Roux)  units  are  about  equivalent 
to  one  U.S.A.  unit;  and  the  usual  prophylactic  dose  of 

1  Bull.  No.   43,    Hyg.    Lab.    U.S.   Pub.  Health  and  Mar.  Hosp. 
Service,  1908. 

2  Brit.  Med.  Journ.,  1914,  ii.  609;  1915,  ii.  849. 


10  c.c.  of  the  Pasteur  Institute  serum  is  equal  to  about 
600  U.S.A.  units.  In  a  considerable  number  of  cases 
recorded  in  the  past  few  years  the  number  of  units 
administered  is  stated ;  when,  however,  this  important 
detail  is  missing,  some  idea  of  the  amount  injected  can  be 
arrived  at  if  it  is  recollected  that,  according  to  its  place  of 
manufacture,  10  c.c.  of  antitetanic  serum  contains  approxi- 
mately 1,500  U.S.A.,  500  to  1,000  Roux,  10  to  20  Behring, 
and  400,000  Tizzoni  units. 

Experimental  value  of  antitoxin. — From  experi- 
ments made  in  the  laboratory,  in  which  all  the  factors  are 
under  control,  there  can  be  no  doubt  that  tetanus  antitoxin, 
if  given  along  with,  or  shortly  after,  a  dose  of  the  toxin,  has 
the  power  of  preventing  the  occurrence  of  the  characteristic 
symptoms  and  of  death.  Donitz l  finds  that,  whereas  a 
certain  dose  of  antitoxin  suffices  to  neutralize  a  definite 
quantity  of  the  toxin  when  it  is  injected  at  the  same  time, 
if  a  space  of  four  minutes  is  allowed  to  elapse  between  the 
administration  of  the  toxin  and  that  of  the  antidote,  then 
a  slightly  larger  amount  of  the  latter  is  needed.  If  eight 
minutes  intervene,  then  six  times  the  original  neutralizing 
dose  of  antitoxin  is  required  ;  if  sixteen  minutes,  then 
twelve  times  the  dose  ;  and  at  the  end  of  one  hour,  twenty- 
four  times  the  amount  of  antitoxin  is  requisite,  and  so  on 
up  to  ninety-six  hours.  Tims,  as  in  the  case  of  diphtheria, 
the  "  mass  "  action  of  large  doses  of  antitoxin  may  be  exerted 
for  a  certain  time  after  the  poison  is  injected.  This  has 
been  clearly  shown  by  von  Graff  and  Menschikoff,-  who 
were  able  to  remove  the  toxin  from  saturated  liver-cells  by 
soaking  them  in  antitoxin ;  whilst  Kraus  and  Amiradziti :; 
further  showed  that  the  antitoxin  does  not  penetrate  the 
toxin-loaded  cells,  but  that  the  toxin  must  diffuse  out 
before  it  can  be  neutralized — the  rate  of  the  diffusion 
being  accelerated  by  the  presence  of  a  high  concentration 

1  Deut.  med.  W'och.,  1897,  p.  430. 

2  Centralbl.f.  Bakt.,  I.  Orig.,  1912,  Ixi.  220. 

:i  Zeitschr.f.  Immunitiitsfursch.,  I.  Orig.,  vi.  1. 


USE    OF   TETANUS   ANTITOXIN  145 

of  antitoxin  in  the  surrounding  fluid.  *  But  there  comes  a 
time  when  the  toxin  has  entered  so  closely  into  combination 
with  the  cells  that  no  amount  of  antitoxin  is  capable  of 
withdrawing  it.  After  that  time  even  the  minimal  lethal 
dose  is  of  necessity  fatal. 

Further,  even  if  the  blood  of  an  animal  is  rendered 
antitoxic  to  tetanine,  injection  of  this  poison  into  the 
substance  of  its  brain  will  still  produce  a  fatal  effect  as 
surely  as  if  no  protective  power  had  been  gained. 

General  considerations  on  the   use  of  tetanus 

antitoxin. — Tetanus  is  a  comparatively  rare  disease  in 
this  country,  and  in  times  of  peace  is  comparatively  uncom- 
mon in  most  civilized  parts  of  the  world.  Hence  statistics 
are  difficult  to  collect,  and  are  generally  founded  on  small 
numbers  of  cases,  insufficient  for  the  formation  of  accurate 
deductions.  Further,  the  disease  may  occur  in  an  acute 
or  in  a  more  or  less  chronic  form,  these  varieties  merging 
one  into  the  other  with  no  distinct  dividing  line ;  and 
in  chronic  cases,  where  the  incubation  period  has  been 
lengthy,  the  mortality  is  much  less  than  in  the  acute. 
Owing  to  these  peculiarities,  it  is  difficult  to  calculate 
what  the  mortality  from  the  disease  was  before  the  intro- 
duction of  antitoxin ;  and  the  statistical  method,  such  as 
was  vised  for  demonstrating  the  value  of  diphtherial  anti- 
toxin, is  more  liable  to  be  vitiated  by  errors  of  observation. 

In  recorded  cases  of  tetanus  it  is  generally  impossible  to 
gather  a  definite  opinion  as  to  the  severity  of  the  case,  and 
hence  it  is  difficult  to  realize  what  would  have  been  the 
chance  of  recovery  without  the  use  of  antitoxin ;  while  a 
comparison  of  a  small  series  of  six  or  eight  cases  with  a 
theoretical  general-mortality  figure,  of  the  vague  description 
which  we  have  just  indicated,  gives  very  little  information. 
On  the  other  hand,  the  observer's  opinion  in  any  individual 
instance,  as  to  the  effects  produced  by  the  remedy  in  abating 
symptoms  or  conducing  to  recovery,  is  unreliable. 

The  data  obtained  by  means  of  experiments  on  animals, 
as  to  the  behaviour  of  the  poison  in  the  body  and  as  to  the 
K 


146       SERUMS,   VACCINES,   AND   TOXINS 

neutralizing  effects  of  the  antitoxin,  afford  very  clear 
indications  as  to  what  we  may  expect  from  the  latter  in 
the  treatment  of  the  disease.  Nothing  is  more  definitely 
established  than  that  there  comes  a  period  of  time  at  which 
the  toxin  is  so  closely  attached  to  the  cells  of  the  nervous 
system  that  no  amount  of  antitoxin  will  suffice  to  with- 
draw it  or  to  counteract  its  effects.  This  usually  occurs 
very  early  in  the  disease;  so  that  the  vital  question  that 
presents  itself  is,  whether  it  is  not  already  too  late  for 
the  antitoxin  to  have  any  good  effect  when  the  disease  has 
declared  itself,  Le.  when  the  symptoms,  by  which  alone  the 
infection  can  be  recognized,  have  appeared.  To  this  there  can 
be  but  one  answer.  It  is  impossible  to  know  in  any  given 
case  whether  the  amount  of  toxin  which  has  been  taken  up 
by  the  nerves  is  sufficient  to  cause  a  fatal  termination.  By 
administering  antitoxin  we  cut  off  the  supply  of  the  poison 
and  prevent  further  absorption.  It  might  be  that  a 
quantity  of  toxin  just  short  of  the  minimal  fatal  dose  had 
been  absorbed  at  the  time  when  the  case  came  under 
treatment.  If  the  remedy  were  given  at  once,  the  further 
absorption  of  the  poison  would  be  stopped,  and  the  balance 
would  be  turned  in  the  patient's  favour;  whereas,  if  any 
delay  in  giving  the  remedy  were  allowed  to  arise,  time 
might  be  afforded  for  the  absorption  of  the  additional 
amount  of  toxin  necessary  to  cause  death.  Hence  theo- 
retical reasons  lead  us  to  the  conclusion  that  the  antitoxin 
should  be  used  in  all  cases  directly  they  come  under  treat- 
ment. No  brilliant  statistics  of  cures  are  to  be  looked 
for ;  probably  only  a  few  cases  will  be  saved  :  but  we  can 
never  know,  till  death  has  actually  ensued,  that  the  case 
before  us  is  not  one  of  the  exceptions  in  which  the  use  of 
antitoxin  will  turn  the  scale  towards  recovery. 

Statistics  of  the  use  of  antitoxin  in  tetanus.— 
We  have  already  pointed  out  that  tetanus  is  too  uncommon 
a  disease  for  the  statistics  of  it  to  be  valuable ;  further,  the 
use  of  antitoxin  is  of  comparatively  recent  introduction,  so 
that  no  large  number  of  cases  is  available  for  the  study  of 


STATISTICS   OF    TETANUS  147 

its  effects.  The  present  European  War  has,  it  is  true,  un- 
happily supplied  a  considerable  number  of  cases,  the  data 
concerning  which  may  be  regarded  as  adequate ;  but  suffi- 
cient time  has  not  yet  elapsed  for  their  classification  and 
analysis.  We  are  therefore  still  obliged  to  rely  upon  earlier 
statistics.  Lambert1  collected  262  cases,  of  which  151 
recovered,  giving  a  total  mortality  of  42'36  percent.  These 
were  divided  into  124  acute  cases,  of  which  35  recovered, 
giving  a  percentage  mortality  of  71*77;  and  138  chronic 
cases,  of  which  116  recovered,  leaving  a  mortality  of  only 
15-94  per  cent.  On  these  figures  he  pronounces  strongly 
in  favour  of  the  use  of  the  remedy,  especially  in  the  chronic 
cases,  in  which  the  previous  mortality  was  about  40  per 
cent.  ;  in  these  his  figures  show  a  reduction  in  mortality 
(due  to  antitoxin)  of  approximately  24  per  cent.  Abbe  ~ 
saw  0  cases  of  tetanus  in  pre-antitoxin  days,  of  which 
only  1  recovered ;  whereas  of  9  others  treated  with  this 
remedy  7  survived.  Of  these  latter  cases  5  were  severe 
in  type,  and  3  of  them  recovered.  For  reasons  already 
given  it  does  not  seem  worth  while  to  set  forth  in 
detail  the  figures  given  by  different  writers.  Rozenraad3 
quotes  the  following  records :  Engelmann,  54  cases  treated 
with  antitoxic  serum,  mortality  28  per  cent. ;  Lund,  167 
cases,  mortality  35  per  cent. ;  and  Kochler,  96  cases,  mor- 
tality 34-4  per  cent. 

Busch4  collected  147  cases  with  a  mortality  of  44  per 
cent.  Schley  5  quotes  Packard  and  Wilson's  figures,  viz. 
1,216  cases  with  a  mortality  of  42  per  cent.,  and  Mosche- 
witz's  461  cases  with  mortality  40*3  per  cent.  It  is  im- 
possible to  say  how  far  these  various  collections  of  cases 
overlap  one  another. 

Mode  Of  administration. — Subcutaneous  injection  of 

1  Op.  cit. 

2  Ann.  of  Surg.,  1900,  xxxi.  273. 

3  Quinzaine  Therapeut.,  1904,  p.  63. 

4  Arch.f.  MM.  Chir.,  1907,  Ixxxii.,  Heft  1. 
6  N.Y.  Med.  Record,  1904,  p.  616. 


148       SERUMS,   VACCINES,    AND   TOXINS 

antitoxin  was  that  first  employed  in  tetanus,  as  in  diph- 
theria, and  a  large  proportion  of  the  cases  on  record  have 
been  treated  by  this  method  alone.  It  was,  however, 
pointed  out  that  the  antitoxin  was  only  slowly  absorbed 
by  this  route,  one  or  two  clays  elapsing  before  the 
maximum  concentration  of  antitoxin  in  the  blood  is 
reached ;  whereas  it  was  important  to  neutralize  the  toxin, 
which  had  already  got  the  start  of  the  antidote,  as  quickly 
as  possible.  Hence  intravenous  injection  certainly  seems 
to  be  preferable  to  the  subcutaneous  route,  as  being 
speedier  in  its  action — a  question  of  minutes  only. 

Both  of  these  methods  effect  a  neutralization  of  the 
poison  circulating  in  the  blood,  but  they  do  not  avail  to 
counteract  that  which  has  already  reached  the  nervous 
system.  Two  methods  adapted  to  achieve  this  end,  if  it  be 
possible  in  any  way,  have  been  recommended,  namely,  the 
injection  of  the  antitoxin  into  the  space  between  the  dura 
mater  and  the  brain  (subdural)  or  spinal  cord  (intrathecaf), 
and  injection  directly  into  the  brain-substance  (intni- 
cerebral).  Each  of  these  has  its  advocates,  but  for  ease 
and  safety  of  administration  and  generally  for  effective- 
ness the  injection  of  the  serum  intraspinally  after  lumbar 
puncture  is  undoubtedly  the  best. 

In  favour  of  the  subdural  method,  Leyden J  points  to 
the  results  of  11  cases  which  he  has  collected,  among 
which  there  were  6  deaths  and  5  recoveries.  Two  of 
the  latter  were  cases  of  his  own.  It  is  certain  that  the 
cerebro-spinal  fluid  contains  toxin  in  fatal  cases  of  tetanus, 
and  the  subdural  injection  will  neutralize  this.  It  is, 
however,  uncertain  whether  the  toxin  is  taken  up  by  the 
central  nervous  system  directly  from  the  fluid  in  which 
it  is  bathed.  Meyer  and  Ransom,  as  already  quoted,  do 
not  think  that  it  is;  but  there  is  no  doubt  that  other 
substances,  such  as  cocaine,  are  thus  absorbed.  Further 
experiment  seems  necessary  in  order  to  decide  this  question 
positively. 

1  Dent,  med.  JFoch.,  1901,  No.  29,  p.  477. 


USE    OF   TETANUS  ANTITOXIN  149 

Jacob l  states  that  he  was  successful  in  saving  two-thirds 
of  his  cases  at  the  Charite*  Hospital  in  St.  Petersburg 
which  were  treated  by  the  subdural  method.  He  withdraws 
10  c.c.  of  cerebro-spinal  fluid  by  lumbar  puncture,  and  then 
slowly  injects  10  to  20  c.c.  of  antitoxin.  Penna 2  gave 
the  remedy  beneath  the  cerebral  membranes,  using  large 
quantities  of  serum — in  one  case  60  c.c.  at  a  dose.  Daily 
injections  were  given,  amounting  in  all  to  100-240  c.c.  per 
case.  Of  5  patients,  3  recovered  and  2  died — the  latter 
of  intercurrent  pneumonia,  not  of  tetanus.  Wallace  and 
Sargent  3  report  4  cases  treated  by  injection  into  the  spinal 
theca;  of  these  3  recovered,  .1  being  a  severe  case  and  2 
subacute. 

Hoffmann4  contrasts  13  cases  treated  by  subcutaneous 
injection  only,  with  7  deaths,  with  a  further  16  cases 
(including  extremely  severe  cases  with  short  incubation 
periods)  treated  by  intraspinal  injections,  with  only  2 
deaths. 

Theory  is  very  strongly  in  favour  of  the  method  of  intra- 
cerebral  injection.  It  has  been  pointed  out  that,  if  the 
toxin  is  injected  directly  into  the  brain,  no  amount  of  anti- 
toxic power  in  the  blood  will  avert  a  fatal  issue.  The 
toxin  appears  to  be  passed  on  from  one  cell  to  another  in 
the  central  nervous  system,  and  it  is  to  be  supposed  that 
the  antitoxin  will  also  be  thus  diffused.  Roux  5  saved  35 
out  of  45  guineapigs  inoculated  with  tetanine  by  this 
method,  whereas  by  the  subcutaneous  injection  he  had  only 
2  recoveries  out  of  17  animals.  Letoux  6  records  4  cases  of 
recovery  in  human  patients  after  intracerebral  injection. 

1  JRousski  Vratch,  Jan.  and  Feb.,  1902  (abstr.  in  Journ.  of  the 
dmer.  Mcd.  Assoc.,  1902,  i.  977). 

-  Semana  Medica^  Oct.  31,  1901  (ubstr.  in  Journ.  of  the  Amer.  Mcd 
Assoc.,  1902,  p.  602). 

3  Lancet,  1904,  i.  642.     (Jf.  Neugebauer,  Wien.  klin.  Woch.,  1905, 
No.  18. 

4  Beitr.  s.  klin.  C'hir.,  Oct.,  1907,  Iv. 

5  Quoted  by  Abbe,  op.  cit. 

6  Semaine  Med.,  1901,  p.  349. 


150       SERUMS,    VACCINES,    AND    TOXINS 

He  administered  10  c.c.  of  antitoxin  into  each  hemisphere. 
Abbe !  also  speaks  in  favour  of  the  intracerebral  route. 

Bruce,2  on  analysing  215  cases  of  tetanus  treated  in 
the  home  military  hospitals,  came  to  the  conclusion  that 
intrathecal  injections,  alone  or  combined  with  intravenous 
and  subcutaneous  injections,  of  antitetanic  serum  gave  the 
lowest  mortality. 

Intraneural  injection  has  also  been  practised,  in  view  of 
the  supposed  route  by  which  the  poison  is  absorbed.  Good 
results  are  recorded  in  individual  cases.3  It  is  best  to  make 
use  of  the  subdural  method  in  addition. 

In  a  recent  communication  Ashhurst  and  John1  advise 
the  simultaneous  use  of  several  modes  of  administration 
of  the  serum.  They  expose  the  nerves  leading  from  the 
wound  by  surgical  incision,  and  inject  into  them,  as  near 
to  the  spinal  cord  as  possible  and  towards  this  structure, 
as  much  serum  as  can  be  introduced.  They  then  give 
intrathecally  3,000  units  of  the  antitoxin,  and  the  same 
quantity  or  twice  as  much  into  the  muscles  around  the 
wound,  while  10,000  units  are  administered  intravenously. 
The  intraneural  and  intrathecal  injections  are  repeated  daily, 
and  the  intravenous  dose  may  also  be  repeated  if  desired. 
Coincidently  the  wound  is  carefully  cleaned  up,  and  chloral 
and  bromide  are  given  by  mouth  or  rectum  to  diminish 
the  irritability  of  the  spinal  cord. 

Behring 5  considers  that  no  good  results  are  to  be 
hoped  for  from  the  use  of  antitoxin  if  it  is  administered 
more  than  thirty  hours  after  the  onset  of  symptoms,  or  if 
less  than  100  units  (on  his  system)  are  given.  Accord- 
ing to  the  experience  of  Moeller,6  even  if  these  postu- 

1  Op.  cit. 

2  Brit.  Med.  Juurn.,  1915,  ii.  593. 

3  See  Rosenraad,  Quinzaine  Therapeitt.,  1904,   p.   03  ;    Apert   and 
L'Hermitte,  ibid.,  199  ;  Sicard,  ibid.,  199  ;  Clairmont,  Wien.  klin.  Woch. , 
1905,  No.  49  ;  Rogers,  Med.  Record,  1904,  Ixv.  813,  Ixvi.  12. 

4  Amer.  Jottrn.  Med.  Sci.,  1913,  cxlv.  806,  clxvi.  77. 

5  Deul.  med.  Woch.,  1900,  No.  2. 

6  Ibid.,  1901,  No.  47,  p.  814. 


DOSE   OF   TETANUS  ANTITOXIN          151 

lates  are  fulfilled,  no  great  fall  in  the  mortality  is  to  be 
looked  for. 

A  considerable  number  of  isolated  cases  are  reported, 
but  as  they  are  by  different  observers,  using  different  brands 
of  serum  and  employing  a  variety  of  methods,  little  would 
be  gained  by  tabulating  them.  Tizzoni1  considers  that  the 
serum  which  he  prepares  is  superior  to  that  of  Behring, 
while  German  writers  3  apparently  hold  that  the  disease  in 
Italy  is  less  virulent  than  in  their  own  country.  No  exact 
data  seem  to  be  available  for  estimating  the  truth  of  these 
international  amenities. 

On  the  whole,  as  was  to  be  anticipated  on  the  theoretical 
grounds  already  set  out,  the  curative  treatment  of  tetanus 
by  antitoxin  is  disappointing,  as  compared  with  the  results 
obtained  in  diphtheria.  Nevertheless,  it  is  our  duty  to  give 
the  remedy  a  trial  in  all  cases,  since  it  is  possible  that  it 
will  do  good,  and  it  can  in  any  case  do  practically  no  harm. 

Dose  of  antitoxin. — As  already  mentioned,  records 
of  cases  generally  state  the  number  of  cubic  centimetres 
of  serum  injected,  and  not  the  number  of  units.  A  dose 
is  usually  from  10  to  20  c.c.  ;  and  although  the  amount  of 
antitoxic  units  contained  in  the  serum  is  not  often  noted 
on  the  bottle,  and  hence  is  not  known  to  the  adminis- 
trator, it  may  be  gauged  by  reference  to  the  equivalents 
given  on  p.  144.  Behring  advises  that  not  less  than  100  of 
his  units  (4,000  U.S.A.  units)  should  be  given  at  once. 
Amounts  of  10  to  20  c.c.  are  easily  administered  sub- 
durally,  around  either  the  spinal  cord  or  the  brain,  or 
into  the  lateral  ventricles.  From  3  to  5  c.c.  can  be  in- 
jected into  the  substance  of  the  brain  by  slow  instillation. 
Amounts  up  to  50  or  100  c.c.  can  be  given,  if  necessary, 
intravenously.  The  important  point,  however,  is  that  the 
injection  must  be  given  boldly  and  in  adequate  dose,  and 
the  dose  must  be  repeated  frequently. 

Prophylactic  use  of  antitoxin.— There  is  ample 

1  Riforma  Medica,  1901,  i.  366. 

-  See  Pfeiffer,  Zeitschr.  f,  Heilkunde,  Bd.  xxxiii.,  Heft  2. 


152       SERUMS,    VACCINES,    AND   TOXINS 

evidence  that  antitoxin  proves  of  greatest  service  in  the 
prevention  of  tetanus.  Experiments  on  animals  point 
strongly  in  this  direction.  Actual  results  are  also  en- 
couraging. In  veterinary  practice  some  striking  statistics 
are  quoted  by  MacFarland.1  In  one  of  the  large  factories 
for  the  production  of  antitoxin  (diphtherial)  much  trouble 
was  at  one  time  caused  by  the  incidence  of  tetanus  among 
the  horses.  At  last  systematic  use  of  prophylactic  injec- 
tions of  antitoxin  was  instituted,  and  the  result  was  that, 
whereas  in  one  year  (1898)  the  death-rate  among  the 
animals  was  10  per  cent.,  in  the  year  following  it  fell  to 
1  per  cent.,  and  in  the  year  after  that  to  a  mere  fraction. 
Nocard  -  reports  concerning  a  certain  district  that  of  2,708 
horses  injected  with  antitoxin  none  developed  tetanus,  al- 
though among  other  horses  in  the  same  part  of  the  country 
there  were  220  cases  of  the  disease.  Vaillard3  adds  13,124 
in  the  practice  of  eight  veterinary  surgeons,  between  the 
years  1898-1906,  treated  prophylactically  with  tetanus 
antitoxin  without  a  single  case  of  tetanus  occurring,  and 
notes  that  two  neighbouring  veterinarians  saw  139  cases 
of  tetanus  in  other  practices  during  the  same  period. 
Herhold,4  who  was  surgeon  to  the  German  contingent 
on  the  expedition  to  Pekin,  at  first  lost  several  patients 
by  tetanus.  Afterwards  he  used  prophylactic  injections  in 
all  cases  of  crushed  wounds  contaminated  with  dirt,  and 
no  more  cases  of  the  disease  occurred.  Fisch  5  considers 
that  the  preventive  use  of  the  antitoxin  was  of  consider- 
able service  in  the  epidemic  which  occurred  at  St.  Louis 
from  contaminated  diphtherial  antitoxin. 

The  records  of  Independence  Day  in  the  United  States 
afford  the  best  examples  of  the  results  of  the  systematic 
use  of  prophylactic  doses  of  antitoxin.  Each  celebration 

1  Journ.  of  the  Amer.  Med.  Assoc.,  July  4,  1903,  p.  34. 

2  Quoted  by  Yaillard,  "Medicaments  Microbiens."     Paris,  1912. 

3  Op.  cit. 

4  Deut.  med.  Woch.,  1901,  No.  30,  p.  479. 

5  Interstate  Med.  Journ.,  Dec.,  1901. 


STATISTICS   OF   TETANUS   ANTITOXIN   153 

is  responsible  for  over  4,000  cases  of  dirty  and  contused 
wounds,  which  are  followed  in  many  instances  by  tetanus ; 
and  in  1903  there  were  406  deaths  from  this  disease. 
Since  1904  antitoxin  has  been  extensively  used,-  and, 
although  the  numbers  of  the  wounded  have  not  appreciably 
diminished,  there  has  been  a  consistent  fall  in  the  mortality 
from  tetanus,  as  will  be  seen  by  the  following  table  :x — 


STATISTICS  OP  INJURIES,  INDEPENDENCE 

DAY,  U.S.A. 

DEATHS 

_i 

TETAXUS 

YEAR 

TETANUS 

OTHER 

DISEASES 

INJURIES 

DEATHS 
PER 
1,000  INJURIES 

1903    . 

.  406 

60 

3,983     . 

.     .     102 

1904    . 

.     91 

92 

3,986     . 

.     .       23 

1905    . 

.     87 

95 

4,994    . 

.     .       17 

1906    . 

.     75 

83 

5,308     . 

.     .       14 

1907    . 

.     62 

102 

4,249     . 

.     .       14 

1908   . 

.     55 

108 

5,460     . 

.     .       10 

1909    . 

.  125 

90 

5,092     . 

.     .       24 

1910    . 

.     67 

64 

2,792     . 

.     .       24 

1911    . 

.     10 

47 

1,546     . 

.     .         6 

1912    . 

.       6 

35 

947     . 

.     .         6 

1913    . 

.       3 

29 

1,131     . 

.     .         3 

Although  statistics  are  not  yet  available,  the  experience 
of  the  surgeons  employed  on  the  Western  front  during  the 
first  year  of  the  present  European  War  leads  them  to 
express  a  high  opinion  of  the  value  of  antitetanic  serum 
used  prophylactically. 

At  the  same  time,  it  seems  necessary  to  admit  that  an 
injection  of  antitoxin  is  not  a  certain  preventive  of  tetanus, 
as  Reynier2  records  that  in  a  hospital  in  Paris,  in  conse- 
quence of  an  outbreak  of  the  disease,  a  patient  who  had 
received  a  prophylactic  injection  nevertheless  developed 

1  Journ.  of  the  Amer.  Med.  Assoc.,  Sept.,  1912,  and  Sept.,  1913. 

2  Quoted  by  Moeller,  Deut.  ined.  Woch.,  1901,  No.  47,  p.  814. 


154       SERUMS,    VACCINES,    AND   TOXINS 

tetanus.  She  finally  recovered,  whereas  two  other  patients 
died  of  the  disease ;  so  it  is  possible  that  even  here  some 
good  was  done,  and  what  would  otherwise  have  been  a 
fatal  attack  was  rendered  milder.  Walther1  records  the 
case  of  a  German  soldier  wounded  by  shrapnel,  who  received 
10  c.c.  antitoxin  as  a  prophylactic,  but  developed  tetanus 
the  following  day. 

We  may  conclude  that,  in  countries  where  tetanus  is 
a  comparatively  common  complication,  all  cases  of  crushed 
or  dirty  wounds  should  receive  a  prophylactic  injection  of 
antitoxin ;  and  American  experience  would  place  the  pro- 
phylactic dose  at  from  500  to  1,500  or  more  U.S.A.  units, 
according  to  the  length  of  time  that  has  elapsed  since  the 
infliction  of  the  injury.  How  long  the  protection  will  last 
is  not  known.  As  the  serum,  being  derived  from  the  horse, 
is  exactly  analogous  to  diphtherial  antitoxin,  it  seems 
legitimate  to  assume  that  it  will  be  excreted  or  neutralized 
at  the  same  rate  as  the  latter :  hence  we  may  conclude  that 
the  protection  will  remain  effective  for  about  three  weeks ; 
and  Rowan2  records  a  case  where  protection  for  a  period 
of  twenty-four  days  was  obtained  from  a  dose  of  1,500 
U.S.A.  units.  Dehne  and  Hamburger,3  however,  believe 
that  it  ceases  after  about  one  week ;  hence  the  French 
practice  of  repeating  the  prophylactic  dose  at  the  end  of 
seven  to  ten  days  is  sound.  Levin  4  is  of  a  similar  opinion, 
and  therefore  advocates  a  series  of  relatively  small  doses 
rather  than  one  large  one. 

Ill  effects  Of  antitoxin. — The  same  by-effects  may 
be  expected  to  occur  after  the  use  of  tetanus  antitoxin  as 
after  antidiphtherial  serum,  since  it  is  horse's  serum  which 
is  used  in  both  cases.  Di  Gaspero 5  describes  a  case  in 
which  a  fatal  issue  occurred,  due,  as  he  thinks,  to  serum ; 

1  La  Presse  Med,  1914. 

2  Wien.  M».  Woch.,  1907,  Nos.  1-3. 

3  Journ.  Mod.  Assoc.,  1910,  p.  533. 

4  Zeltschr.  f.  Immunitatsforsch.,  1909,  i.  (Orig.)  3. 

5  "  Die  Tberap.  der  Gegenwarfc,"  1902,  p.  139.         - 


CEREBRAL   EMULSION    IN    TETANUS     155 

but  the  accuracy  of  this  inference  is  very  doubtful.  Rashes 
of  various  kinds — scarlatiniform,  bullous,  urticarial,  etc. — 
are  also  recorded. 

TREATMENT  WITH  CEREBRAL  EMULSION 

In  view  of  the  great  affinity  of  the  substance  of  the 
central  nervous  system  (brain  and  spinal  cord)  for  tetanus 
toxin,  use  has  been  made  of  emulsion  of  fresh  brain-sub- 
stance as  treatment  for  the  disease.  Krokiewicz1  recorded 
16  cases  in  which  use  was  made  of  this  preparation,  an 
untiltered  emulsion  being  injected  hypodermically.  Of  the 
16  cases,  13  recovered,  3  of  them  being  severe  attacks. 

When  we  consider  the  difficulty  with  which  an  emulsion 
of  cerebral  substance  must  be  absorbed  and  reach  the 
circulation,  it  is  easy  to  realize  that  the  curative  action  of 
such  a  remedy  must  necessarily  be  slower  than  that  of 
antitoxic  serum.  The  latter  should  therefore  have  the 
preference,  if  it  be  available.  If,  however,  no  antitoxin 
be  at  hand,  it  would  certainly  be  not  only  legitimate  but 
also  advisable  to  make  trial  of  cerebral  emulsion.  The 
mode  of  action  of  the  two  remedies  is  theoretically  the 
same,  the  receptors  of  the  cerebral  ceils  being  available 
in  the  emulsion  to  anchor  the  toxin  and  neutralize  it, 
just  as  the  free  receptors  (side-chains)  do  in  the  antitoxin. 
The  diffusion  of  the  emulsified  cells  must  be  less  rapid 
than  that  of  the  cast-off  receptors — which  are  presumably 
separate  molecules,  not  whole  cells. 

CONCLUSIONS 

1.  Tetanus  antitoxin  cannot  be  expected  to  cure  any 
large  proportion  of  patients  in  whom  the  disease  has 
developed,  but  it/  should  be  given  in  all  cases  of  tetanus, 
since  it  may  just  turn  the  scale  in  the  patient's  favour 
by  neutralizing  the  poison  circulating  in  the  blood,  although 
it  may  not  reach  that  already  absorbed  by  the  nervous 
system. 

1  Klin,  therap,  Woch.,  Feb.  8,  1903. 


156       SERUMS,    VACCINES,    AND    TOXINS 

2.  Curative  dose, — In  all  cases,  intraspinal  injection 
through  a  lumbar  puncture  (of  high-valency  serum  equal 
in  volume  to  the  amount  of  cerebro-spinal  fluid  that  can 
be   first  withdrawn — at   least  5,000  U.S.A.  units,  or  the 
equivalent  in  Continental  serums)  should  be  practised,  im- 
mediately   followed  by   intravenous   injection    of    at    least 
5,000  U.S.A.  units.     These  injections  may  be  repeated  as 
often  as  seems   necessary,   at   intervals  of   six  to  twelve 
hours. 

3.  Intracerebral  injection  possibly  offers  the  best  chance 
of  neutralizing  the  poison  already  absorbed,  and  may  be 
used  in  very  severe  cases,  intravenous  or  subcutaneous  in- 
jections being  employed  at  the  same  time. 

4.  Prophylactic  dose. — In  countries  where  tetanus  is 
common,  prophylactic  injections  of  antitoxin  should  be  used 
in  all  cases  of  crushed  wounds,  especially  those  which  have 
been  soiled  by  dirt  or  other  foreign  matter,  and  in  deep 
incised   wounds   similarly    contaminated.      The   antitoxin 
may  be   given   subcutaneously  or  intramuscularly    in    the 
vicinity  of  the  wound,  or  intravenously. 

5.  The  prophylactic  dose  may  be  stated  as  500  to  1,000 
U.S.A.   units,    the   latter   being   an   ample   dose   if  used 
immediately.      If,    however,    any   appreciable    interval  has 
elapsed   since  the    receipt  of  the  injury,   this  latter  dose 
must  be  doubled,  trebled,  or   quadrupled,  and  the  serum 
must  be  injected  before  the  surgical  toilet  of  the  ivound  is 
undertaken,   to  obviate    the   danger  of  opening    up  fresh 
areas  for  the  absorption  of  unneutralized   toxin ;   for  this 
reason,  too,  a  large  prophylactic  dose  of  serum  must  be 
injected  intravenously  immediately   before   any  extensive 
operation  is  commenced. 

6.  The  prophylactic  dose  may  be  repeated  a  week  later 
with  advantage ;  in  severe  wounds  the  dose  should  certainly 
be  repeated  once  or  twice  at  intervals  of  seven  days. 


CHAPTER  VII 
SNAKE-BITE 

Classification  Of  snakes. — The  poisonous  varieties 
of  snakes  belong  chiefly  to  the  families  Colubridse  and 
Viperidae.  The  best-known  kinds  which  belong  to  the 
Colubrine  group  are  the  Cobras  (Naja),  the  Coralline 
snakes  (Elaps),  the  Kraits  (Bungarus),  and  the  Death- 
adder  (Noteckis).  To  the  Viperine  division  belong  the 
Common  Viper  (Vipera  berus),  Russell's  Viper  (Daboia), 
the  Puff-adder  (F.  arielans),  the  Rattlesnakes  (Crotalus), 
the  Bush-master  (Lachesis),  the  Tiger-snake  (Hoplocephahis), 
and  the  Copperhead  (Denlsonia).  The  poisonous  water- 
snakes  (HydrophincK)  are  classed  as  Colubrine  snakes.  The 
classification  depends  mainly  on  small  differences  in  the 
teeth  and  the  bones  of  the  head.1 

The  amount  of  poison  injected  in  an  individual  case  de- 
pends on  the  efficiency  with  which  the  stroke  was  delivered, 
while  the  virulence  of  the  poison  varies  with  the  health  and 
vigour  of  the  snake  at  the  moment,  and  to  some  extent 
with  the  season  of  the  yeai-.  Caltnette,  using  cobras  that 
had  been  kept  in  captivity  for  some  time,  believed  that  a 
full-sized  cobra  would  inject  at  one  stroke  about  30  to  45 
mg.  of  venom  ;  but  Cunningham  puts  the  quantity  at  254 
mg.,  and  Rogers  at  249  mg.  Lamb,  dealing  with  freshly- 
caught  cobras,  reckons  the  average  amount  as  200  mg.2 

Different  animals  vary  somewhat  in  the  degree  of  suscep- 

1  An  account  of  the  varieties  of  poisonous  snakes  may  be  found 
in    Calmette's    "  Venoms,   Venomous    Animals,   and  Antivenomous 
Therapeutics,"  trans,  by  Austin  ;  London,  1908. 

2  See  Rogers,  Ind.  Med.  Gaz.,  Sept.,  1904,  p.  332  ;  Lamb,  Glasgow 
Med.  Jotirn.,  Feb.,  1903,  p.  85. 

157 


158       SERUMS,    VACCINES,    AND    TOXINS 

tibility  which  they  present  to  the  action  of  snake-poison. 
Rabbits,  guineapigs,  and  herbivorous  animals  in  general 
seem  more  susceptible  than  carnivora,  such  as  the  cat  or  the 
dog.  Man  is  probably  about  equal  in  this  respect  to  the 
latter  class.  The  minute  dose  of  poison  which  is  capable  of 
causing  symptoms  is  illustrated  by  the  experience  of  the 
late  Mr.  Frank  Buckland,  who  accidentally  pricked  his 
finger  in  the  process  of  dissecting  the  body  of  a  rat  killed 
by  the  bite  of  a  poisonous  snake.  Only  an  infinitesimal 
amount  of  fluid  could  thus  have  entered  his  system,  and 
the  original  dose  of  poison  had  been  diluted  by  diffusion 
throughout  the  body  of  the  animal ;  nevertheless,  alarming 
symptoms  of  faintness  and  collapse  ensued. 

Nature  Of  the  poison. — The  poison  may  be  collected 
by  killing  the  snake  and  dissecting  out  the  gland  and  recep- 
tacle ;  or  the  snake  may  be  "  milked  "  by  pressure  on  the 
sac ;  or  it  may  be  made  to  bite  on  a  watch-glass  covered 
with  an  india-rubber  membrane,  and  the  poison  thus  collected 
in  the  glass.  The  last  method  is  probably  the  best.  The 
poison  is  dried  in  vacua,  and  may  be  preserved  indefinitely 
in  this  condition. 

It  has  long  been  known  that  the  poisons  of  different 
snakes  are  not  identical  in  their  effects  ;  the  poisons  of  the 
viperine  group  having,  as  a  rule,  a  more  intense  local  action, 
those  of  the  colubrine  family  rapidly  producing  a  general 
intoxication.  Calmette,  however,  to  whom  we  are  indebted 
for  the  original  preparation  of  an  anti-venomous  serum 
(antivenene),  considered  that  the  main  toxin,  at  all  events, 
was  the  same  in  all  venoms,  and  could  be  counteracted 
by  one  and  the  same  antitoxin.  This  view  was  combated 
by  Martin,  who,  as  the  result  of  his  experiments,  came 
to  the  conclusion  that  there  were  two  substances  present 
in  the  venom  of  all  snakes,  varying,  however,  in  propor- 
tions in  different  species.  One  was  a  globulin,  coagulable 
by  heat ;  the  other  a  peptone,  which  was  resistant  to  it. 
The  former  is  responsible  for  the  general  nervine  intoxica- 
tion, the  latter  for  the  local  effects  and  blood-changes. 


NATURE    OF   VENOM  159 

Lamb J  has  given  reasons  for  rejecting  these  views. 
He  is  inclined  to  think  that  the  poison  of  each  genus 
of  snakes  is  to  some  extent  specific,  containing  a  kind 
of  poison  not  met  with  in  other  varieties.  Thus  he 
holds  that  though  the  poisons  of  the  cobra  and  the  daboia 
are  each  complex,  no  single  constituent  is  common  to  both. 
The  reasons  for  this  will  be  clearer  when  we  come  to  consider 
the  action  of  antitoxic  serum  as  an  antidote  to  the  poisons 
of  different  snakes.  In  a  later  article,  written  with  C.  J. 
Martin,3  the  statement  is  made  as  the  result  of  a  study  of 
many  venoms  and  antivenenes,  that  "  antivenomous  serums 
are  highly  but  not  strictly  specific."  Lamb  originally  con- 
sidered that  in  all  probability  the  poisonous  element  was 
not  proteid  in  nature.  He  showed  that  the  proteins  in  the 
different  venoms  are,  as  far  as  can  be  determined,  the 
same  in  all,  while  the  effects  produced  are  diverse.  This 
would  bring  snake-poison  into  the  same  category  as  the 
toxins  of  diphtheria  and  tetanus,  of  which  the  former  was 
shown  to  be  developed  in  a  non-albuminous  medium,  while 
the  latter,  according  to  Dean,  is  also  of  the  nature  of  a 
ferment  rather  than  an  albumin.  Lamb3  appears,  how- 
ever, to  have  changed  his  opinion  and  now  believes  in 
the  proteid  nature  of  the  poison.  Faust,4  on  the  other 
hand,  states  that  he  precipitated  a  poison  (ophiotoxin\ 
five  times  as  toxic  as  crude  venom,  from  cobra- venom 
by  means  of  alcohol  after  all  the  proteins  had  been 
removed. 

Action  of  venom. — Locally,  the  effects  produced  by 
snake-bite  are  swelling,  redness,  and  ecchymosis ;  if  the 
patient  survive  the  first  effects,  cellulitis  and  sloughing  of 
the  parts  may  occur,  and  the  oadema  may  spread  up  the 

1  "Scientific  Memoirs  by  Officers  of  the  Med.  and  Sanit.  Depts.  of 
the  Govt.  of  India,"  No.  5,  "  Specificity  of  Anti- venomous  Sera,"  1903. 

2  Allbutt  and  Rolleston's  "System  of  Medicine,"  vol.  ii.,  Part  2, 
1907,  p.  815. 

3  Glasgow  Med.  Jottrn.,  Feb.,  1903,  p.  8(». 

4  Arch.  f.  exp.  Path.,  1907,  Ivi.  236. 


160       SERUMS,   VACCINES,    AND   TOXINS 

affected  limb.  The  general  effect  of  the  poison  is  shown  in 
its  action  upon  the  nervous  system,  which  takes  the  form  of 
depression,  collapse,  nausea  or  vomiting,  incoordination, 
paralysis,  and  convulsions,  ending  in  coma  and  death  by 
asphyxia  or  heart-failure.  Haemorrhagic  discharges  from 
mucous  membranes  are  sometimes  seen. 

Experimentally,  snake-poison  is  found  to  have  a  solvent 
action  on  the  red  corpuscles  of  the  blood  (haemolysis). 
Lamb  finds  that  both  cobra-  and  daboia-venom  have  this 
property.  Cobra-poison,  however,  acts  more  powerfully 
outside  the  body  than  within  it,  while  daboia-venom  is  more 
haemolytic  in  vivo  than  in  vitro.  The  hsemolytic  substance 
in  cobra- venom  is  not  coagulable  by  heat.  According  to 
Harnack  and  Hildebrand,1  the  venom  of  the  rattlesnake 
(crotcdotoxiri)*  acts  almost  instantaneously  when  adminis- 
tered intravenously,  but  more  slowly  when  injected  into 
a  muscle.  Small  repeated  doses  produce  wasting,  and  a 
waxy  degeneration  of  the  muscle-fibres  is  seen  after  death. 
Rattlesnake-venom  is  attenuated  by  heat  and  by  the  action 
of  hydrochloric  acid.  Cobra-hsemolysin  is  also  weakened 
by  heat,  but  recovers  its  virulence  on  standing.3  Flexner 
and-Noguchi*  assert  that  the  haemolytic  agent  in  venom 
is  of  the  nature  of  a  copula  or  intermediary  body  (see  p.  8). 
The  complement  which  is  necessary  to  complete  its  action 
on  the  blood-corpuscles  is  contained  within  the  corpuscles 

1  Miineh.  med.  Woth.,  1912,  p.  142''.. 

2  Crotaline,  or  rattlesnake-venom,  has  been  used  for  medical  treat- 
ment, especially  in  epilepsy,  for  which  Mays  advises  dose*  of  ^V5  to 
ffa  grain,  given  every  fourth  day.    The  same  writer  believes   this 
substance  to  be  useful  in  chronic  pulmonary  tuberculosis  :  he  makes 
a  solution  of  1  gr.  in  a  mixture  of  100  min.  of  glycerin  and  400  of 
water,  giving  doses  of  sjf  to  yj^  gr.  into  the  "lung  cavity"  ':  sub- 
stance of  the  lung).     The  solution  may  also  be  used  as  a  nebula 
(Med.  Record,  1913,  Ixxxiii.  561).     See  aho  Spangler,  JV«r  York  Med. 
Journ.,  Sept.  9,  1911  ;   and  Fackenheim,  Munch,  tutd.  JToth.,  Sept.  5. 
1911. 

3  See  Flexner  and  Noguchi,  Journ.  Med.  Research,  1904,  vi.  363  : 
Morgenroth  and  Pane,  Bvockem.  Zeittchr.,  1906,  i.  354. 

4  Univ.  of  Pennsylvania  Med.  Bull.,  1902,  xiv.  438,  and  xv.  345. 


EFFECTS   OF   VENOM  161 

themselves  (endo-complernent).  This  view  has  been  con- 
firmed by  Kyes,1  who  was  successful  in  preparing  a  chemical 
compound  resulting  from  the  union  of  the  copula  and  lecithin. 
This  he  named  "cobra-lecithide."  It  has  a  direct  hsemolytic 
action.  Snake-poison  also  possesses  the  power  of  agglutinat- 
ing red  corpuscles,  the  clumps  thus  formed  being  disinte- 
grated again  by  the  action  of  permanganate  of  potassium. 
The  agglutinative  power  is  removed  by  heating  the  venom 
to  75°  or  80°  0.,  whereas  the  hsemolytic  power  still  remains 
after  this  treatment,  showing  that  the  two  properties  are 
dependent  on  distinct  toxins.  Leucocytes  are  destroyed 
by  the  poison  as  well  as  red  corpuscles  (leucolysis).  The 
different  kinds  of  leucocytes  contained  in  rabbit's  blood  are 
unequally  affected  by  the  leucolytic  substance,  the  lympho- 
cytes being  the  least  susceptible. 

The  ecchymoses  seen  in  cases  of  snake-bite  are  due  to 
the  action  of  the  poison  on  the  endothelial  cells  forming 
the  lining  membrane  of  the  capillaries.  This  action  is 
analogous  to  haemolysis,  and  is  due  to  a  destructive  "  lysis  " 
of  these  cells  by  a  special  substance,  which  is  called  by 
Flexner  and  Noguchi  "  hsemorrhagin,"  from  its  effect 
in  producing  haemorrhages.  It  is  suggested  by  these  ob- 
servers that  possibly  similar  substances  may  exist  in  the 
blood  of  patients  suffering  from  the  various  forms  of  pur- 
pura.  These  authors  further  state  that  venom  has  the 
power  of  dissolving  other  cells  besides  blood-corpuscles  (e.g. 
liver-cells,  spermatozoa,  etc.).  Daboia-venom  also  liquefies 
gelatin  by  means  of  a  special  ferment. 

According  to  Lamb  3  the  venom  of  the  daboia  produces 
intravascular  clotting  of  the  blood,  whereas  cobra-poison, 
on  the  other  hand,  has  an  exactly  opposite  effect,  causing  a 
diminution  in  the 'coagulability  of  the  blood.  Death  in  cases 
of  bite  by  the  daboia  results  from  the  extensive  character 

1  Eerlin.  Uin.  Woch.,  1903,  Nos.42,  43. 

2  "  Scientific  Memoirs  of  the  Government  of  India,"  No.  4,  1903, 
"  On  the  Action  of  the  Venoms  of  the  Cobra  (Naja  tripudians)  and  of 
the  Daboia  (D.  Iti(ssellii)"  etc. 

L 


162       SERUMS,   VACCINES,    AND    TOXINS 

of  this  clotting.  Curiously  enough,  it  appears  that  a  small 
dose  of  the  poison,  insufficient  to  cause  this  phenomenon,  is 
followed  by  a  diminution  of  coagulative  power ;  and  if  this 
has  once  been  produced,  no  subsequent  injection  of  further 
doses  of  the  poison  will  any  longer  produce  clotting  (cf. 
antianaphylaxis).  This  peculiar  phenomenon  is  not  repro- 
duced in  vitro,  and  is  dependent  on  some  obscure  vital 
action.  The  substance  in  cobra-venom  which  reduces  the 
coagulative  power  of  the  blood  is  not  a  protein  coagulable 
by  heat.  The  addition  of  snake-venom  to  blood  has  the 
effect  of  reducing  the  bactericidal  power  of  the  latter  by 
depriving  it  of  the  necessary  complements,  which  becomo 
fixed  to  the  copulas  present  in  the  venom.  The  latter 
does  not  contain  complement. 

The  element  in  venom  which  acts  on  the  nervous  system 
is  called  by  Flexner  and  Noguchi  "  neurotoxin."  It,  too, 
is  of  the  nature  of  a  copula,  and  acts  by  fixing  a  suitable 
complement  to  the  nerve-cells.  These  observers  also  found 
that  the  brain  was  the  organ  in  the  body  which  contained 
the  most  neutralizing  substance  for  venom,  i.e.  that  its 
cells  have  the  greatest  affinity  for  the  toxin.  An  animal 
injected  with  a  minimal  lethal  dose  of  venom  mixed  with 
emulsion  of  brain  lived  many  hours  longer  than  one  which 
received  the  same  quantity  of  poison  in  blood-serum  or 
similar  fluid.  After  death  acute  degeneration  of  the  nerve- 
cells  (chromatolysis)  is  found  (Hunter).1  Rogers-  states 
that  the  poison  of  the  sea-snake,  Enhydritia,  has  an  action 
resembling  that  of  curare. 

The  principal  poisonous  substances  in  snake-poison  are 
therefore  (1)  hsemolytic,  (2)  leucolytic,  (3)  hsemorrhagic, 
and  (4)  neurotoxic.  The  bodies  having  these  separate 
actions  are  probably  different  in  the  various  kinds  of 
poisonous  snakes.  Hence  it  is  evident  that  the  term 
"  snake-poison  "  or  venom  includes  a  very  complex  group 
of  chemical  substances. 

1  Glasgow  Med.  Journ.,  Feb.,  1903,  p.  98. 
'  Lancet,  1904,  i.  349. 


PREPARATION   OF  ANTIVENENE         163 
ANTIVENENE 

Preparation  of  antivenene. — The  posubility  of  pre- 
paring an  antitoxic  serum  (antivenene)  for  the  treatment 
of  snake-bite  was  first  practically  demonstrated  by  Calmette, 
of  Lille.  His  serum  is  manufactured  by  injecting  a  horse 
with  gradually  increasing  quantities  of  a  mixed  venom, 
containing  80  per  cent,  of  cobra-poison  and  20  per  cent, 
of  viperine  venom.  The  mixture  is  heated  before  the 
injections  are  given,  as  the  crude  poison  is  so  intensely 
toxic  that  the  horses  are  often  killed  by  the  minute 
quantities  used  for  immunization.  Thus  MacFarland ] 
states  that  he  lost  two  out  of  three  horses  on.  which  he 
practised  the  inoculations.  It  is  therefore  necessary  to 
proceed  with  the  greatest  caution  in  these  injections.  A 
further  difficulty  is  met  with  in  the  process,  owing  to  the  need 
of  procuring  large  quantities  of  venom  for  the  later  injections 
— a  need  which  is  not  easily  satisfied,  for  obvious-  reasons. 
It  is  advisable  to  administer  to  the  horse  before  inoculation 
one  or  more  protective  doses  of  antivenene,  in  order  to 
enable  it  to  withstand  the  first  injections  of  the  poison. 
Otherwise  the  method  adopted  is  practically  the  same  as 
that  already  described  for  the  antitoxins  of  tetanus  and 
diphtheria.  Tidswell "  took  more  than  three  years  in  im- 
munizing a  horse  against  the  venom  of  the  Australian 
tiger-snake,  owing  to  a  combination  of  the  above-mentioned 
difficulties. 

Action  of  antivenene. — Calmette  claims  that  the 
antivenene  which  he  prepares  is  capable  of  neutralizing  the 
effects  of  the  venom  of  any  snake,  whatever  the  species  to 
which  it  belongs.  The  mixture  of  venoms  which  he  uses 
for  the  inoculation  is  designed  to  render  the  horse  resistant 
to  the  poisons  of  viperine  as  well  as  colubrine  snakes,  even 
if  it  be  not  the  case,  as  he  apparently  holds,  that  the  venoms 
of  all  kinds  of  snakes  are  identical.  It  has,  however,  been 

1  Journ.  of  the  American  Med.  Assoc.,  1901,  xxxvii.  1597. 

2  Australasian  Med.  Gaz.,  April  21,  1902. 


164       SERUMS,    VACCINES,    AND    TOXINS 

pointed  out  by  Uaniia  and  Lamb  l  that  the  heating  process 
to  which  the  mixed  poison  is  subjected  before  injection,  in 
order  to  render  it  less  virulent,  is  capable  of  destroying  the 
potency  of  viperine  poison  altogether,  or  almost  entirely. 
Hence  only  the  cobra-venom  is  actually  left  to  immunize 
the  horse. 

Experience  seems  to  confirm  this  view  to  a  groat 
extent.  Thus  Tidswell  finds  that  Calmette's  serum  has 
no  effect  in  neutralizing  the  poison  of  the  Australian 
tiger-snake  ( Hoplocephalus  curtus) ;  nor  had  an  antivenene 
prepared  from  the  venom  of  this  snake  any  antidotal  power 
against  the  poisons  of  other  snakes  met  with  in  the  same 
continent  (Echis,  Notechis).  Lamb  similarly  found  that 
cobra-antivenene  has  no  antitoxic  power  against  the  bite  of 
the  daboia  ;  and  in  a  later  memoir  he  pointed  out  that  it 
was  unavailing  against  the  poisons  of  the  snakes  known  as 
Bungarus  c&ruleus  and  Echis  carinata.  Serum  prepared 
with  the  venom  of  the  hoplocephalus  by  Tidswell  had  no 
neutralizing  effect  upon  the  venom  of  bungarus,  cobra,  or 
daboia,  and  an  anticrotalus  serum  failed  to  influence  the 
course  of  symptoms  produced  by  the  venom  of  other  snakes 
(Noguchi).  On  the  other  hand,  Korbel 2  found  antivenene 
useful  in  the  bites  of  vipers  (F.  aspis,  V.  berus,  V.  ursini, 
V.  ammodytes),  and  Rogers  3  founcl  that  it  neutralized  the 
venom  of  the  king-cobra  (Hamadryas),  of  the  krait  (Bun- 
garus), and  of  the  sea-snake  (Enhydrina). 

These  results  are  of  considerable  practical  importance. 
If  the  venoms  of  the  different  snakes  are  thus  specific  jn 
nature,  so  that  a  serum  prepared  from  one  of  them  has  no 
neutralizing  effect  on  poison  derived  from  another  species, 
the  question  of  the  practical  therapeutics  of  snake-bite 
becomes  much  less  simple  than  was  originally  hoped  by 
Calmette.  It  would  seem  necessary  to  have  at  hand  in  all 
cases  a  supply  of  serums  for  all  the  different  varieties  of 

1  Journ.  of  Pathol.  and  Sacter.,  1902,  viii.  1. 

-  men.  med.  Woch.,  1908,  p.  399. 

3  Indian  Mtd.  Gaz.,  Sept.,  1904,  p.  332. 


EFFICACY   OF   ANTIVENENE  165 

snakes  found  in  any  district,  or  else  to  prepare  a  polyvalent 
serum  by  injections  of  the  poisons  of  all  of  these  reptiles. 
It  does  not  seem  to  be  known  at  present  how  far  the  latter 
suggestion  is  feasible.  On  the  other  hand,  it  is  evident  that 
if  separate  serums  were  prepared  for  each  kind  of  snake,  it 
would  often  be  necessary  to  inject  all  of  them  in  a  case  of 
snake-bite,  since  the  patient  could  not  be  expected  to  know 
what  was  the  kind  of  snake  which  bit  him.  Bites  from 
snakes  often  occur  at  night,  when  it  would  be  impossible 
for  anyone  to  identify  the  assailant ;  while  those  who  are 
not  skilled  zoologists  would  in  any  case  not  be  likely  to 
know  one  poisonous  variety  from  another. 

With  regard  to  the  neutralizing  action  of  antivenene  on 
the  different  constituents  of  snake-poison,  there  seems  some 
divergence  of  opinion.  Flexner  and  Noguchi l  state  that 
antivenene  is  capable  of  inhibiting  the  effects,  not  only  of 
the  neurotoxin  or  main  poisonous  element,  but  also  of  the 
luemolytic  and  other  materials.  On  the  other  hand,  Mac- 
Farland  2  finds  that  it  is  very  difficult,  if  not  impossible,  to 
produce  immunity  to  the  local  irritation  of  the  poison.  He 
considers,  however,  that  the  remedy  should  be  used  in  all 
cases,  as  the  counteraction  of  the  most  deadly  toxin  allows 
the  body  to  concentrate  all  its  resisting  powers  on  repelling 
the  local  irritant.  According  to  Auche  and  Vaillant-Hovius3 
the  presence  of  antivenene  does  not  prevent  haemolysis 
altogether,  but  renders  it  less  intense  and  more  transitory. 
If  the  neural  toxin  of  snake-poison  be  removed,  the  body 
which  gives  rise  to  coagulation  of  the  blood  may  still  cause 
death,  if  it  is  present  in  a  sufficient  amount. 

Noguchi  4has  prepared  an  antivenene  against  rattlesnake- 
bite  (anticrotalus  serum),  and  Vital 5  prepares  two  serums, 

1  Journ.  Exper.  Med.,  1902,  vi.  277. 

2  Op.  cit. 

3  Archives  de  Med.  Expenmentale  et  d? Anatomic  Pathol.,   1902, 
xiv.  221. 

*  Univ.  Penna.  Med.  Bull.,  Aug.,  1904,  p.  154. 

5  Quoted  by  Alabrese,  Abstr.  Centralbl.  f.  inn.  Med.,  1907,  p.  152. 


166       SERUMS,    VACCINES,    AND    TOXINS 

one  against  crotalus  and  the  other  against  bothrops,  and 
mixes  them  to  form  a  polyvalent  remedy. 

Standardization  of  antivenene.— For  the  purpose 
of  experimental  study  of  the  action  of  venom  and  of  anti- 
venene on  animals  it  is  necessary  to  arrive  at  some  standard 
of  virulence  and  of  protective  power  respectively.  This  is 
done  by  determining  the  minimal  lethal  dose  for  a  certain 
kind  of  animal  (rabbit  or  rat),  calculating  the  weight  of 
the  animal  in  grammes.  Thus  Lamb  found  that  O'Oo  mg. 
(0'00005  grm.)  of  the  venom  of  Echis  carinata  per  kilo- 
gramme of  body-weight  was  fatal  to  rabbits ;  in  other 
words,  a  rabbit  weighing  1,000  grin,  would  be  killed  by 
the  above  quantity  of  poison,  while  one  weighing  1,500 
grm.  would  require  half  as  much  again.  Of  the  venom 
of  Bunyarus  fasciatus  0'7  mg.  was  required  to  produce  the 
same  effect.  The  venoms  of  different  snakes  thus  differ 
markedly  in  their  actual  toxicity.  Further,  as  was  pre- 
viously stated,  different  species  of  animals  vary  somewhat 
in  their  susceptibility  to  snake-poison,  while  the  actual 
toxins  are  probably  very  different  in  the  various  kinds  of 
snakes.  Hence  no  accurate  measurement  of  toxins  and 
antitoxins  applicable  to  all  can  possibly  be  arranged. 

The  only  antitoxic  serum  on  the  market  is  Calmette's 
antivenene,  which  is  effective  for  cobra-poison.  This  is 
standardized  by  experiments  on  rabbits.  The  amount  of 
serum  which  will  protect  a  rabbit  weighing  2,000  grin. 
against  the  smallest  amount  of  the  toxin  that  would 
otherwise  kill  it  is  said  to  contain  2,000  units  of  antitoxin. 
The  Pasteur  Institute  of  India  also  issues  an  antitoxic 
serum,  which  is  twice  as  strong  as  Calmette's.  The 
whole  matter  is  as  yet  in  so  experimental  a  stage  that 
the  standardization  of  the  antivenene  is  scarcely  of  practical 
therapeutic  importance. 

Dose  Of  antivenene. — Doses  of  10  to  30  c.c.  are  recom- 
mended by  Calmette.  Lamb,  however,  considers  that  this 
amount  of  a  serum  of  the  ordinary  strength  is  not  sufficient 
to  protect  against  the  whole  amount  of  poison  which  a  full- 


DOSE    OF    ANTIVENENE  167 

grown,  healthy  snake  can  inject  at  a  bite,  and  he  advises 
the  use  of  not  less  than  100  c.c.,  if  this  quantity  be  available. 
Rogers  calculates  that  as  much  as  400  to  800  c.c.  may  be 
required.  If  any  time  has  elapsed  since  the  bite,  the  remedy 
should  be  given  intravenously.  If  the  case  be  seen  at  once, 
injection  into  the  neighbourhood  of  the  bite  may  be  em- 
ployed. Ordinary  measures,  such  as  the  constriction  of  the 
bitten  limb  by  a  tight  ligature  above  the  seat  of  injury, 
pressure  to  squeeze  out  any  poison  lying  free  in  the  punc- 
tures, and  stimulating  remedies,  must  not  be  omitted. 

CONCLUSIONS 

1.  Calmette's  antivenene  should  be  used  promptly  in 
all  cases  of  snake-bite.     It  protects  effectually  against  cobra- 
bites.     It  probably  has  little  effect  against  the  venom  of 
snakes  belonging  to  other  genera ;  but  this  matter  is  still 
under  investigation,  and  in  any  case  it  is  difficult,  if  not 
impossible,  to  be  certain  of  the  kind   of  snake  which  has 
inflicted  the  bite  in  countries  where  several  kinds  are  met 
with. 

2.  The  dose  should  be  100  c.c.  or  more,  if  possible,  and 
should  be  injected  intravenously  as  soon  as  possible  after 
the  bite. 

3.  Fuller  investigation  is  necessary  with  regard  to  the 
manufacture  of  a  polyvalent  serum  applicable  to  the  bites 
of  more  than  one  kind  of  poisonous  snake. 


CHAPTER   VIII 
HYDROPHOBIA  (RABIES) 

Causation.— Up  to  the  present  time  the  actual  cause 
of  hydrophobia,  or  rabies  as  it  is  called  when  it  affects  the 
lower  animals,  is  absolutely  unknown.  A  large  number  of 
organisms  have  at  one  time  and  another  been  announced  as 
the  excitants  of  the  disease  (bacteria,  protozoa,  etc.),  but  no 
one  of  them  has  so  far  withstood  the  test  when  its  claims 
were  more  fully  investigated. 

In  1903  Negri1  discovered  certain  bodies  in  the  large 
nerve-cells  of  the  cerebral  cortex,  cerebellum,  etc.,  which  he 
maintained  represented  one  phase  of  the  life-cycle  of  a 
specific  parasite.  Some  of  the  organisms  contain  a  number 
of  small  refringent  bodies  like  spores.  They  appear,  as  a 
rule,  just  before  the  onset  of  symptoms  in  the  rabbit,  and 
were  found  in  one  case  of  human  hydrophobia.  Negri 
regarded  the  bodies  as  protozoa,  and  stated  that  they 
occurred  only  in  hydrophobia  and  not  in  other  conditions. 
They  are  easily  demonstrable  by  ordinary  staining  methods. 
Noguchi2  believes  that  he  has  observed  multiplication  of 
these  parasites  in  artificial  media,  and  confidently  asserts 
that  they  are  the  causal  agents  of  the  disease  ;  but  Volpino,3 
repeating  Noguchi's  experiments,  declares  that  the  multi- 
plication forms  are  merely  droplets  of  lipoid — and  there  the 
matter  rests  for  the  moment.  Remlinger  and  Riffat  Bey  4 
state  that  they  have  succeeded  in  passing  the  virus  of 

1  Zeitschr.f.  Hygiene  u.  Infectionskrankh.,  1903,  xliv.  f>07. 
*  Journ.  Exper.  Med.,  1913,  xviii.  314. 

3  Presse  Medicate,  1914,  p.  79  ;  also  Fatholoyica,  Jan.  1,  1914. 

4  Compt.  Rend.  Soc.  de  BioL,  1903,  Iv.  730.  . 

168    • 


VIRUS   OF   RABIES  169 

rabies  through  a  Berkefeld  filter  ;  if  this  be  confirmed,  it  is 
necessary  to  conclude  that  the  infective  agent  is  capable  of 
existing  in  a  very  minute  form,  at  one  period,  at  all  events, 
of  its  life-cycle. 

The  virus  or  infective  material,  whatever  its  nature, 
resides  in  the  saliva  of  infected  animals,  as  is  evident  from 
the  fact  that  the  disease  is  most  often  conveyed  by  bites  of 
rabid  animals ;  but  it  exists  in  still  greater  concentration 
in  the  central  nervous  system  (brain  and  spinal  cord).  It 
is  probably  not  present  in  the  blood  or  in  most  of  the  organs 
of  an  animal  which  has  died  from  the  disease,  but  is  found 
in  the  secretions  of  certain  glands  (lachrymal,  mammary, 
pancreatic) ;  possibly  the  poison  is  excreted  by  these  chan- 
nels. The  toxin  of  rabies  bears  very  close  resemblance 
to  that  of  tetanus  in  many  of  its  properties.  Thus  it  has 
a  marked  affinity  for  the  nervous  system,  passing  to  the 
central  portions  of  this  by  way  of  the  peripheral  nerves 
(cf.  p.  139);  it  produces  first  a  stimulation  of  the  reflex 
activity  of  the  nervous  centres,  though  this  is  followed  later 
on  by  paralysis  ;  its  effects  on  the  cerebrum  are  manifested 
by  excitement  and  delirium  analogous  to  the  phenomena 
noted  as  the  result  of  injections  of  tetanine  into  the  brain- 
substance.  Further,  the  occurrences  in  the  wound  itself 
bear  some  resemblance  to  those  met  with  in  tetanus,  as  in 
each  case  the  injured  point  may  cicatrize,  but  with  the  onset 
of  the  disease  pain  may  occur  in  the  scar ;  while  Pace l  has 
shown  that  the  virus  of  rabies  remains  locally  at  the  seat 
of  inoculation,  as  do  the  bacilli  of  tetanus.  Deep  wounds 
of  a  lacerated  nature  are  those  most  liable  to  give  rise  to 
hydrophobia,  just  as  injuries  of  this  sort  are  those  most 
commonly  followed  by  tetanus. 

Statistics  as  to  the  percentage  number  of  all  cases  bitten 
by  rabid  animals  which  subsequently  develop  hydrophobia 
are  somewhat  difficult  to  obtain.  Rose  Bradford  3  puts  it 

1  Ann.  de  VInst.  Pasteur,  1903,  xvii.  293. 

2  Art.   "  Hydrophobia "  in  "  Quain's   Dictionary  of   Medicine," 
3rd  edition,  edited  by  Montague  Murray.     1902. 


170       SERUMS,   VACCINES,    AND    TOXINS 

at  16  to  25  per  cent. ;  some  authorities  give  rather  higher, 
others  lower,  figures.  It  is,  at  any  rate,  certain  that  all 
who  are  bitten  do  not  develop  the  disease,  even  apart  from 
treatment.  This  fact  is  of  importance  in  estimating  the 
benefits  derived  from  preventive  inoculations.  When  once 
it  has  appeared,  the  disease  is  invariably  fatal.  Persons 
bitten  through  their  clothes  are  not  very  likely  to  be 
attacked  by  hydrophobia,  as  the  virus  is  wiped  off  the 
teeth  of  the  animal  in  passing  through  the  dress-material. 
Natives  of  India  and  of  other  hot  countries  are  thus  more 
liable  to  suffer  from  hydrophobia  than  are  Europeans 
resident  in  the  same  districts,  owing  to  the  scantiness 
of  their  clothing. 

Incubation  period. — The  incubation  period  of  hydro- 
phobia is  very  long,  varying  from  about  three  weeks  to 
(possibly)  some  years.  As  to  the  extremely  long  periods 
assigned  to  the  incubation  of  this  disease,  there  is  consider- 
able doubt.  Kaspareck  and  Teuner l  relate  a  case  in  which 
the  disease  occurred  seven  months  after  infection,  in  spite 
of  prophylactic  inoculation.  Pampoukis,2  out  of  a  number 
of  cases  not  treated  in  any  way,  found  that  9-3  per  cent, 
occurred  within  the  first  month  after  the  bite,  ;~>3-4  per 
cent,  in  the  second  month,  and  37 '2  in  the  third  month. 
The  average  incubation  period  in  the  United  States  is  said 
to  be  forty-nine  days.3  Probably  six  weeks  may  be  looked 
on  as  the  average  period  of  time  between  the  injury  and 
the  onset  of  symptoms. 

Modification  of  the  virus  of  rabies. — Although 

nothing  is  known  of  the  poisonous  material  which  gives 
rise  to  this  malady,  yet  experiments  show  that  it  resides 
chiefly  in  the  nervous  system  of  infected  animals,  and  that 
it  can  be  modified  in  various  ways.  Thus,  light,  air,  and 
desiccation  rapidly  destroy  the  virulence  of  rabic  matter. 
Heat,  also,  has  the  same  effect,  and  so  has  the  addition  of 

1  Berlin.  Jclin.  JJ'oc/i.,  1902,  Sept.  8,  p.  s  1 1. 

-  Ann.  de  Flnst.  Pasteur,  1{»00,  xiv.  111. 

3  Leading  article,  Med.  Record,  1912,  Ixxxi.  :;i  I. 


ANT1EABIC   VACCINATION  171 

antiseptic  drugs,  though  the  resistance  offered  to  these  last 
is  considerable.  Carbolic  acid  (1  :  20)  cannot  be  relied  upon 
to  destroy  the  virulence  of  emulsions  of  brain-substance  in 
less  than  an  hour,  and  perchloride  of  mercury  (1  :  1,000) 
takes  three  hours  to  sterilize  this  fluid.  Digestion  with 
gastric  juice  diminishes  the  virulence  of  infected  spinal 
cords ;  and  this  method  of  producing  a  vaccine  has  been 
employed  in  Italy,  and  is  known  as  the  "  Italian  method." 
Post-mortem  decomposition  has  little  effect  in  destroying 
the  virus  of  rabies,  which  may  remain  potent  for  at  least 
a  month  after  burial  of  a  carcase.  Glycerin  is  a  good 
preservative  of  the  virus  (c/.  Vaccinia). 

Exaltation  of  virulence  may  be  effected  by  passing  the 
virus  through  a  succession  of  rabbits,  which  are  very  sensi- 
tive to  the  disease.  After  passage  through  a  large  number 
of  these  animals  the  incubation  period  is  gradually  shortened 
from  about  three  weeks  or  a  little  less  to  a  constant  period 
of  six  or  seven  days.  Virus  of  this  degree  of  virulence  is 
called  by  Pasteur  "  virus  fixe,"  l  and  is  used  in  the  prepara- 
tion of  his  vaccine.  There  is  reason  to  believe  that  the 
virus  which  has  thus  been  exalted  in  virulence  for  rabbits 
is  i-eally  attenuated  for  mankind.  Thus  Nitsch 2  inocu- 
lated himself  with  fresh  cord  from  a  rabid  rabbit,  with  no 
ill  effects. 

ANTIRABIC    VACCINATION 

Pasteur's  vaccine. — Pasteur  discovered  that  by  drying 
the  spinal  cords  derived  from  rabid  animals  for  varying 
periods  of  time  he  could  prepare  a  series  of  viruses  of 
graduated  strengths.  Thus,  if  such  a  cord  is  dried  for  four- 
teen days,  it  loses  all  its  toxic  potency  ;  if  it  is  submitted  to 
this  process  for  only  three  or  four  days,  the  virulence  is  but 
little  reduced.  '  Immunity  to  rabies,  as  to  other  infective 
diseases,  can  be  induced  by  injecting  at  first  minute  doses 
of  the  organism  or  toxin,  and  gradually  increasing  the 

1  As  opposed  to  the  virus  of  uncertain  strength  (virus  dc  la  rue ; 
Strassenwuth')  derived  from  accidentally  infected  animals. 
-'  H'ifin.  !.•!!».  Wwlt  ,  1904,  No.  36,  p.  963. 


172       SERUMS,   VACCINES,    AND   TOXINS 

doses  until  at  last  quite  strong  virus  can  be  employed. 
Graduation  of  the  dose  is  effected  by  taking  equal  amounts 
of  nervous  matter  from  spinal  cords  which  have  been  dried 
for  varying  lengths  of  time.  The  actual  vaccine  consists  of 
a  small  quantity  (2—3  mm.  length)  of  the  substance  of  the 
spinal  cord  of  a  rabbit  which  has  been  killed  by  inoculation 
with  the  "fixed  virus."  This  is  rubbed  up  into  an  emulsion 
with  5  c.c.  of  sterile  broth  or  salt-solution,  and  about  3  c.c. 
of  the  resulting  fluid  is  injected.  A  cord  dried  for  fourteen 
days  is  used  for  the  first  injection :  on  succeeding  occasions 
emulsions  of  less  attenuated  virus  are  used,  till  finally  a 
portion  of  a  spinal  cord  dried  for  only  three  or  four 
days  is  employed.  A  scheme  of  the  actual  doses  may 
be  thus  drawn  up  :  — 


OUDINARY    TREATMENT 

INTENSIVE  TKEATMENT 

Cord  dried 

Cord  dried 

First       day  —  Morning 

14.  days 

2  injections       14  and  13  davs 

Evening 

13     „ 

„                 12  and  11   „" 

Second     „ 

Morning 

12     ., 

„                  10  and    9   ., 

Evening 

11     » 

„              |     8  and    7   ., 

Third       „ 

Morning 

10     „ 

1  injection               6  days 

Evening 

9     » 

,                            n 

Fourth    „ 

Morning 

8     , 

,                      5  days 

Evening 

7    . 

»                                                         M 

Fifth       „ 

Morning 

6     , 

>                           » 

Evening 

6     , 

»                           »> 

Sixth 

Morning 

5     , 

,                        4  days 

Seventh 

5     , 

,                       3  days 

Eighth 

4     , 

,                       4  days 

Ninth 

3     , 

,                      3  days 

Tenth 

5     , 

,                       5  days 

Eleventh 

day 

•5     , 

t                            » 

Twelfth 

„ 

4 

4  days 

Thirteenth 

M 

4     ' 

»5                                                       »» 

Fourteenth  „ 

3     , 

„                       3  days 

Fifteenth 

„ 

3     , 

»                            >» 

On  the  following  i">  days  6  more 
injections  of  5-,  4-,  3-,  5-,  4-,  3-day 
cords  respectively. 


A  more  rapid  form  of  vaccination  is  used  in  cases  in 
which  the  bites  are  about  the  face  and  head,  as  in  these 


ANTIRABIC   VACCINATION  173 

cases  the  incubation  period  is  usually  shorter,  and  therefore 
it  is  important  to  produce  a  full  degree  of  immunity  as 
quickly  as  possible.  This  is  known  as  "  intensive  "  treat- 
ment. It  will  be  seen  in  the  scheme  given  that  the  virulent 
matter  contained  in  a  cord  only  dried  for  three  days  is  here 
administered  on  the  seventh  day,  instead  of  on  the  ninth,  as 
in  the  ordinary  method. 

The  exact  arrangement  of  the  doses  varies  a  little  at 
different  institutions.  Marx  states  that  in  Berlin  it  is  con- 
sidered that  the  virulence  of  the  dried  cord  is  lost  about  the 
eighth  day,  instead  of  the  fourteenth.  Hence  the  Berlin 
authorities  consider  that  the  first  few  days  of  the  Paris 
treatment  are  wasted,  only  material  which  is  quite  inert 
being  inoculated ;  they  therefore  adopt  a  scheme  according 
to  which,  on  the  first  day,  cords  dried  for  seven  and  eight 
days  are  administered  ;  on  the  second  day,  cord  of  six  days' 
drying ;  and  so  on,  reaching  a  cord^dried  for  three  days  on 
the  sixth  day  of  treatment.  Then  cords  of  five,  four,  and 
three  days'  drying  respectively  are  each  administered  for 
two  days,  and  on  the  fourteenth  and  fifteenth  days  cords 
dried  for  only  two  days.  Then  for  the  last  four  days  of  the 
treatment  slightly  less  virulent  material  is  again  employed. 
In  the  intensive  treatment  at]  Berlin  a  cord  of  three  days' 
drying  is  reached  on  the  evening  of  the  third  day  of  treat- 
ment, and  one  of  two  days'  on  the  eighth  day.  The  whole 
intensive  course,  here  also,  lasts  twenty-one  days. 

Nitsch J  recommends  starting  with  cord  dried  for  six 
days,  and  giving  two  injections  daily,  reaching  material  that 
has  been  dried  for  only  one  day  on  the  tenth  (last)  day  of 
treatment.  He  uses  also  larger  quantities  of  the  vaccine 
(3-10  mm.  of  the  cord)  in  emulsion. 

Institutes  for  antirabic  inoculation  are  now  numerous. 
Besides  the  Paris  "  Pasteur  Institute,"  there  exist  institutes 
at  Lille,  Marseilles,  Montpellier,  Lyons,  and  Bordeaux,  in 
France ;  at  Berlin,  Vienna,  Buda-Pest,  Berne,  Odessa,  Con- 
stantinople, Algiers,  Tunis,  Kasauli  (India),  etc.  Different 
1  Jflen.  Idin.  Jl'och.,  1904,  Xo.  36,  p.  959. 


174       SERUMS,    VACCINES.    AND    TOXINS 

modes  of  preparing  a  virus  of  diminished  virulence  for 
purposes  of  inoculation  are  adopted  in  different  countries. 
Thus,  the  Italian  method  of  Tizzoni-and  Centanni  is  to  treat 
the  spinal  cords  with  gastric  juice,  which  has  an  attenuating 
effect  on  the  virus.  Hogyes,  in  Buda-Pest,  merely  dilutes 
an  emulsion  of  virulent  material  to  different  degrees,  using  a 
high  dilution  for  the  first  injections,  and  gradually  raising 
the  concentration  on  succeeding  days.  The  theory  under- 
lying this  procedure  is  that  the  usual  method  of  attenua- 
tion by  drying  alters  the  quantity  of  the  virus,  but  not  its 
quality  ;  in  other  words,  it  kills  a  certain  proportion  of 
the  germs  present,  so  that  a  smaller  number  of  them  are 
injected  at  a  dose,  but  it  does  not  alter  their  virulence. 
Hence,  the  same  result  may  be  obtained  by  simple  dilution. 
The  practical  results  of  this  method  seem  to  bear  out  the 
theory  on  which  it  is  founded,  as  very  favourable  statistics 
of  the  work  of  Hogyes'  Institute  are  shown.  Murillo  l 
records  the  results  obtained  in  3,000  cases  :  6  died  after  treat- 
ment and  17  before  the  course  of  treatment  was  completed. 
Effects  of  antirabic  vaccination. — The  effect  of  Pas- 
teur's method  of  vaccination  in  cases  of  bites  by  rabid  animals 
is  to  produce  an  active  immunity.  Since  the  infective  agent 
in  rabies  is  not  known,  it  is  impossible  to  say  with  certainty 
whether  the  immunity  depends  on  an  antitoxin  or  on  a 
germicidal  state  of  the  serum  and  tissues.  The  latter  is  the 
more  probable,  as  it  has  already  been  shown  that  the  virus 
must  contain  a  living  organism,  not  merely  a  toxin. 
Owing  to  the  long  incubation  period  of  hydrophobia  it  is 
possible  to  induce  immunity  to  the  disease  between  the  time 
at  which  the  bite  was  inflicted  and  that  at  which  the 
symptoms  commence.  Thus  the  treatment  is  in  reality 
prophylactic,  and  not  in  any  way  curative.  If  the  symp- 
toms have  already  set  in,  Pasteur's  treatment  is  of  no  avail. 
The  analogy  to  ordinary  vaccination  (against  small-pox)  is 
exact.  In  the  latter,  vaccination  carried  out  at  the  time 
of  exposure  to  infection  may  protect  against  the  disease, 
1  Centralbl.f.  BaJct.,  1912,  Orig..  Ixii.  606. 


ANTIRABIC   VACCINATION 


175 


since  the  incubation  period  of  vaccinia  is  shorter  than  that 
of  small-pox.  The  difference  here,  however,  is  not  very 
great,  and  more  often  such  vaccination  will  only  lessen  the 
severity  of  the  ensuing  attack  of  small-pox.  In  the  case 
of  rabies,  which  has  an  incubation  period  of  about  six  weeks 
as  a  rule,  there  is  full  time  for  immunity  to  be  produced  before 
the  disease  appears,  and  protection  is  thus  usually  complete. 

Results  of  the  treatment. — A  good  deal  of  scepticism 
was  expressed  as  to  the  value  of  Pasteur's  treatment  when 
it  was  first  introduced  ;  it  was  even  suggested  that  it  might 
result  in  conveying  the  disease  instead  of  preventing  it,  and 

TABLE  SHOWING  DEATHS  FROM  HYDROPHOBIA  AMONG  CASES  TREATED 
IN  PARIS  AND  NEW  YORK 


Year 

PARIS 

NEW  YORK 

No.  of  cases 

Deaths 

Per- 
centage 

No.  of  cases 

Deaths 

Per- 
centage 

1886 

2,671 

25 

0-94 

1887 

1,770 

14 

0-79 

— 

— 

— 

1888 

1,622 

9 

0-55 

— 

— 

— 

1889 

1,830 

7 

0-38 

— 

— 

— 

1890 

1,540 

5 

0-32 

160 

0 

0 

1891 

1,559 

4 

0-25 

100 

2 

2 

1892 

1,790 

4 

0-22 

104 

0 

0 

1893 

1,648 

6 

0-36 

85 

0 

0 

1894 

1,387 

7 

0-50 

89 

1 

1-12 

1895 

1,520 

5 

0-33 

167 

2 

1-19 

1896 

1,308 

4 

0-30 

236 

0 

0 

1897 

1,521 

6 

0-39 

133 

1 

0-74 

1898 

1,465 

3 

0-20 

125 

1 

0-8 

1899 

1,614 

4 

0-25 

159 

2 

1-2 

1900 
1901 

1,420 
1,321 

4 
5 

0-28 
0-38 

}  241 

1 

0-43 

1902 

1.105 

2 

0-18 

— 



— 

1903 

'628 

2 

0-32 







1904 

755 

3 

0-39 







1905 

727  • 

3 

0-41 



— 

— 

1906 

772 

1 

0-13 

— 

— 

— 

1907 

786 

3 

0-38 







1908 

524 

1 

0-19 



— 

— 

1909 

467 

1 

0-21 

— 

— 

— 

1910 

401 

0 

o-oo 







1911 

341 

1 

0-29 

— 

— 

— 

1912 

395 

0 

0-00 

— 

— 

.  — 

170       SERUMS,    VACCINES,    AND    TOXINS 

it  is  possible  that  accidents  of  this  kind  have  actually 
occurred.  At  the  present  time  there  can  no  longer  be  any 
doubt  as  to  its  efficacy,  or  as  to  the  boon  conferred  on  the 
human  race  by  its  discovery.  The  exact  mortality  from 
hydrophobia  in  all  cases  of  bites  by  rabid  animals,  in  times 
before  the  inoculation  treatment  was  introduced,  cannot  be 
exactly  calculated,  but  it  may  safely  be  put  at  not  less  than 
10  per  cent.,  whereas  now  among  the  cases  treated  at  the 
various  Pasteur  Institutes  the  death-rate  has  been  reduced 
to  a  fraction  of  1  per  cent.  The  table  on  p.  175  shows  the 
annual  mortality  at  two  separate  institutions — the  original 
Pasteur  Institute  in  Paris  l  and  the  similar  foundation  in 
New  York.2  It  will  be  seen  from  these  figures  that  the 
death-rate  has  never  reached  1  per  cent,  in  Paris  since  the 
Institute  was  started,  while  in  New  York  the  percentage 
was  only  thrice  over  that  amount  in  the  years  recorded 
above. 

Very  full  statistics  are  published  by  the  various  Pasteur 
institutions  as  to  the  exact  nature  of  the  cases  treated,  in 
which  these  are  tabulated  according  to  the  region  of  the 
bite  and  the  evidence  available  as  to  the  reality  of  the 
disease  from  which  the  dog  or  other  animal  that  inflicted  the 
injury  was  suffering.  In  the  tables  on  pp.  177-8,  Class  A 
contains  cases  in  which  the  dog  was  proved  by  conclusive 
evidence  to  be  rabid  ;  Class  B,  those  in  which  rabies  was 
certified  by  a  veterinary  surgeon,  as  a  result  of  examination  ; 
and  Class  C,  those  in  which  the  nature  of  the  disease  in  the 
animal  was  doubtful.  The  injuries  are  classified,  as  a  rule, 
according  as  they  were  on  the  face,  hands,  or  lower  limbs, 
the  last  being  usually  covered  with  clothes. 

In  the  table  on  p.  178  are  given  the  figures  supplied  by 
the  Indian  Pasteur  Institute  at  Kasauli,3  under  Major  D. 

1  Viala,  Ann.  de  VImt.  Pasteur,  1913,  xxvii.  794. 

2  Eambaud,  Med.  News,  1902,  i.  635.     We  have  not  been  able  to 
find  the  New  York  statistics  for  later  years. 

3  Annual  Report  of  the  Sanitary  Commissioner  with  the  Government 
of  India,  1901,  p.  128. 


ANTIRABIC    VACCINATION 


17V 


Semple,  M.D.,  R.A.M.C.,  which  are  on  a  slightly  different 
system,  the  classes  being,  however,  the  same.  The  statistics 
for  Europeans  and  natives  are  given  separately,  the  latter 
being  liable  to  more  extensive  and  dangerous  bites  owing 
to  their  lighter  clothing.  In  1905,  1,145  persons  were 
treated,  with  7  failures;  and  in  1906,  1,147  persons, 
with  9  failures.1 

TAULE  OF  CASES  TREATED  IN  THE  PASTEUR  INSTITUTES  OF  PARIS 
(1901)  AND  NEW  YORK  (1900-1) 


Bitten  on 
head 

Bitten  on 
hands 

Bitten  on  lower 
limbs 

Total 

V 

•g 

| 

1 

•a 

j 

1 

TS 

j*, 

« 

rrt 

£ 

a 

1 
o 

t« 

•5 

3 

1 

o 

1 

O> 

3 

1 

"3 

a 

5 

1 

H 

H 

M 

H 

o 

1 

o 

M 

Class  A 

20 

0 

0 

93 

0 

0 

58 

0 

0 

171 

0 

0 

13 

1 

7  69 

62 

0 

0 

13 

0        0 

88 

1 

1-13 

Class  B 

80 

0  j     0 

521 

4 

0-77 

184 

0        0 

785 

4 

0-51 

7 

0 

0 

47 

0 

0 

6 

0        0 

60 

0 

0 

Class  C 

23 

1 

4'34 

186 

0 

0 

153 

o 

0 

362 

1 

0-23 

13 

0 

0 

53 

0 

0 

27 

0 

0 

93 

0 

0 

:  Total 

123 

1  I  0-79 

800 

4 

050 

395 

0 

0 

1318 

5 

0-38 

33 

1 

3  03 

162 

0 

0 

46 

0 

0 

241 

1 

04 

In  the  above  table  the  figures  derived  from  the  New  York  Institute 
are  in  dark  type. 

Ferre  2  records  that  at  Bordeaux  there  were  treated,  in 
1901,  100  cases  of  bites  by  rabid  animals,  with  no  deaths. 
Trolard,3  in  Algiers,  treated  1,836  patients,  among  whom 
there  occurred  9  deaths  (0'49  per  cent.).  In  Tunis,4  up  to 
the  end  of  1906,  2,490  cases  had  been  treated,  with  9  deaths 
— a  mortality  of'0'36  per  cent. 

1  Annual  Report  of  the  Sanitary  Commissioner  with  the  Government 
of  India,  1905  and  1906. 

2  Ann.  de  Vlnst.  Pasteur,  1902,  xvi.  391. 

3  Ibid.,  1900,  xiv.  190. 

4  Nicolle,  Arch,  de  Vlnst.  Pasteur  de  Tunis,  1907,  i.  35. 

M 


178       SERUMS,    VACCINES,    AND    TOXINS 


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179 

It  should  be  noted  that  although  we  have  exempli- 
fied certain  points  by  figures  from  the  first  year  of  this 
present  century  (see  tables  on  pp.  177-8),  the  results  of 
treatment  are  so  good  that  statistics  from  any  year  since 
1888  would  have  afforded  equally  convincing  evidence. 

Site  Of  injection. — The  immunizing  injections  are 
generally  administered  subcutaneously  over  the  abdomen, 
as  here  it  is  easy  to  avoid  injury  to  any  nerves.  Kras- 
mitski l  recommends  intravenous  injection  of  a  filtered 
emulsion,  as  producing  a  more  rapid  protection.  He  states 
that  he  has  successfully  treated  70  cases  in  this  manner 
without  any  ill  effects. 

The  importance  of  early  treatment  after  the  injury  has 
been  inflicted  is  proved  by  the  statistics  of  the  Odessa 
Institute,3  which  show  that  of  4,602  cases  treated  within 
the  first  week,  26  deaths  occurred,  giving  a  mortality  of 
0'56  per  cent.  ;  among  961  treated  in  the  second  week, 
16  died,  or  1-66  per  cent. ;  while  among  313  treated  in  the 
third  week,  10  deaths  ensued,  a  mortality  of  3-19  per  cent. 

SERUM   TREATMENT 

AntirablC  serum. — The  serum  of  animals  immunized 
by  the  Pasteurian  method  is  capable  of  neutralizing  the 
virus  of  the  disease.  If  a  sufficient  amount  of  the  serum  be 
mixed  with  an  emulsion  of  virulent  spinal  cord  and  injected 
into  a  rabbit,  no  symptoms  of  disease  will  develop.  As 
previously  mentioned,  in  the  absence  of  all  knowledge  of 
the  causal  agent  of  hydrophobia  it  is  impossible  to  ascertain 
whether  the  serum  is  antitoxic  or  germicidal ;  but  proba- 
bilities are  in  favour  of  the  latter.  Tizzoni  and  Centanni,3 
as  the  result  of  prolonged  experiments,  suggested  the  use  of 
this  serum  as  a  .protective  against  the  disease  in  persons 
who  had  been  bitten,  instead  of  the  Pasteurian  treatment. 

1  Arch,  de  I'lnst.  Pasteur  de  Tunis,  1907,  i.  393. 

2  Quoted  by  Deutsch  and  Feistmantel,  "Impstoffe  und  Sei-a." 
Leipzig,  1903. 

3  Lancet,  1895,  ii.  659,  727,  and  780. 


180       SERUMS,   VACCINES,    AND   TOXINS 

They  consider  that  their  method  is  quicker  and  equally 
certain.  In  some  cases,  also,  this  serum  may  act  as  a  cure 
(in  rabbits)  when  the  symptoms  of  the  disease  are  just 
beginning,  a  period  at  which  ordinary  immunizing  treat- 
ment would  be  absolutely  useless. 

Preparation. — The  method  of  preparing  the  serum  is 
by  inoculating  sheep  with  rabic  material  attenuated  by  the 
"Italian  method  "  (p.  171).  For  the  first  series  of  inocula- 
tions, 17  injections  in^all  are  given  over  a  period  of  twenty 
days,  each  dose  consisting  of  0-25  grm.  of  virus  for  every 
kilogramme  of  body-weight.  The  injections  are  given  sub- 
cutaneously.  Later  on,  immunity  is  kept  up  by  further 
inoculations  at  intervals  of  two  or  two  and  a  half  months. 
The  serum  is  withdrawn  on  the  twenty-fifth  day  after  the  last 
injection.  The  fresh  serum  may  be  dried  at  a  gentle  heat 
over  sulphuric  acid,  and  preserved  in  this  form  indefinitely. 

The  serum  thus  prepared  will  protect  animals  against 

rabies  when  administered  in  doses  equivalent  to  ^ TU^O  °f 

the  body  weight.     One  and  a  half   drops  may  protect  an 

animal  weighing  2  kg.     A  serum  of  this  strength  is  called 

'  typical  serum  "  (S.T.). 

Tizzoni  and  Centanni  state  that  their  serum  is  applicable 
to  man,  and  recommend  that  doses  of  20  c.c.  should  be  used, 
given  in  three  injections — one  half  first,  then  the  remain- 
ing half  in  two  other  doses  at  intervals  of  three  days. 
The  above  amount  is  advised  for  cases  which  come  under 
treatment  within  the  first  four  days  after  the  bite.  For 
cases  seen  between  the  fourth  and  fifteenth  days  the 
amount  of  serum  should  be  doubled,  and  very  large 
quantities  should  be  given  in  cases  of  bites  about  the 
face  and  head. 

Serum  treatment  has  been  carried  out  at  the  Kasauli 
Institute  by  Lieut. -Colonel  Semple  in  the  case  of  badly 
bitten  persons  and  of  those  who  come  for  treatment  some 
time  after  being  bitten.  The  serum  is  prepared  from  ponies. 
"  A  dose  of  serum  is  given  on  the  first  day,  after  which  the 
usual  methods  of  treatment  are  carried  out."  It  is  hoped 


ANTIRABIC   VACCINATION  181 

that  a  passive  immunity  may  thus  be  induced,  so  as  to 
render  the  patient  safe  against  infection  during  the  period 
before  the  active  immunity  comes  into  play.1  It  would  be 
well  to  inject  some  of  the  serum  in  any  case  in  which  pain 
or  discomfort  began  to  be  felt  in  a  wound  inflicted  by  a 
bite,  after  this  had  healed  up,  even  before  any  symptoms 
of  hydrophobia  were  manifested.  The  serum  is  quite 
harmless  in  any  case. 

Tonin2  records  a  case  of  hydrophobia  cured  by  the 
injection  of  salvarsan,  although  Marras 3  found  that  the 
drug  was  valueless  in  the  treatment  of  rabies  experi- 
mentally produced  in  the  laboratory. 

CONCLUSIONS 

1.  If   possible,    in   cases    where    there   is   doubt  as  to 
whether  a  dog  which  has  bitten   anyone   is  rabid  or  not, 
the  animal  should  not  be  killed  at  once,  but  should  be  kept 
under  close  observation.     In  this  way  a  positive  diagnosis 
can  usually  be  made  in  less  than  ten  days ;  otherwise  it 
may  be  necessary  to  have  recourse  to  experimental  inocu- 
lations to  decide  the  question,  and  such  experiments  take 
three  to  four  weeks.      It  would  not  be  safe  to  await  the 
results  of  these  experiments  before  beginning  treatment. 

2.  In    all   cases    of    bites    by    rabid    animals,   recourse 
should  be  had  as  soon  as  possible  to  antirabic  inoculation. 
It  is  important  that  this  should  not  be  delayed.     There  is 
practically  no  danger  in  the  procedure. 

3.  If  for  any  reason  the  preventive  treatment  has  been 
put  off  till  unduly  late,  it  would  seem  advisable  to  inject 
antirabic  serum  as    a    prophylactic   measure,  should  it  be 
available. 

1  See  Ann.  Report  of  the  Sanit.  Commissioner  with  the  Govt.   of 
India,  1902,  p.  115;  Semple,  Lancet,  1908,  i.  1611. 

2  IlPoliclin.,  Sez.  Pract.,  1912. 

3  CentralM.f.  Bakt.,  I.,  Orig.,  1912,  Ixx.  190. 


CHAPTER   IX 

SMALL-POX  AND  VACCINIA 

Causal  agent. — That  small-pox  is  due  to  some  living 
agent  similar  in  nature  to  the  organisms  of  other  infective 
diseases  there  can  be  no  doubt,  but  the  actual  germ  has  not 
been  certainly  isolated.  The  most  probable  parasite  is  that 
named  by  Guarnieri  the  Cytoryctes  variolw,  which  may  be 
identical  with  that  described  by  Councilman  and  by  Calkins. 
The  parasites  described  by  the  latter  authors  are  said  to 
pursue  a  double  life-cycle  within  the  cells,  one  phase  being 
extranuclear,  the  other  intranuclear.  The  latter  is  supposed 
to  correspond  with  the  sexual  cycle  of  the  malarial  parasite. 
It  is  suggested  that  vaccinia  represents  the  extranuclear 
phase  of  the  organism,  whereas  small-pox  consists  essentially 
in  the  invasion  and  destruction  of  the  nuclei.  If  these 
observations  are  confirmed,  the  discovery  will  be  a  matter 
of  great  interest.  We  shall  have  an  instance  of  the  attenua- 
tion of  a  protozoan  parasite  taking  place  by  passage  through 
another  animal,  just  as  occurs  in  the  case  of  vegetable 
parasites  (bacteria).  Further,  a  vaccine  will  have  been 
prepared  against  a  protozoon T  as  well  as  against  bacteria, 
showing  that  the  human  body  has  the  power  of  forming 
protective  substances  against  this  order  of  pathogenic 
agents,  as  well  as  against  vegetable  organisms.  Again,  the 
suggestion  of  an  organism  undergoing  two  different  cycles 
within  the  same  animal  host,  but  in  different  positions  (cell 
and  nucleus),  is  of  considerable  interest. 

1  Ledoux-Lebard  (Compt.  Rend,  de  fAcademie  des  Sciences,  1902, 
cxxxv.  298)  states  that  he  has  prepared  a  specific  antiserum  to  the 
protozoan  organism,  Paraiiicecium  caudatum,  which  is  pathogenic  to 
some  of  the  lower  animals  (rabbits  and  guineapigs). 

182 


PATHOLOGY  OF   SMALL-POX  183 

Identity  of  small-pox  and  cow-pox.— The  question 

of  the  identity  or  difference  of  small-pox  and  cow-pox 
was  long  disputed,  but  there  can  now  be  little  doubt  that 
Jenner  was  right  in  holding  that  the  latter  is  only  small- 
pox modified  by  transmission  to  a  different  animal  which  is 
less  susceptible  to  the  disease.1  Many  attempts  have  been 
made  to  transmit  small-pox  directly  to  cattle,  and  a  certain 
number  of  successful  results  have  now  been  recorded.  Adult 
cows  take  the  disease  with  difficulty ;  calves  are  more  easily 
infected.  A  condition  in  horses  analogous  to  vaccinia 
(equine  variola)  appears  to  be  really  the  same  disease,  and 
lymph  from  this  source  is  capable  of  effecting  vaccination. 

Complications  Of  small-pOX. — Most  of  the  com- 
plications arising  in  small-pox  can  be  distinctly  traced  to 
intercurrent  infection  with  pyogenic  micrococci  (pneu- 
mococci,  streptococci,  or  staphylococci).  It  has  even  been 
said  that  the  pustular  stage  of  the  lesions,  which  has  been 
regarded  as  so  characteristic  of  small-pox,  as  opposed  to 
chicken-pox,  can  be  almost  entirely  prevented  by  careful 
and  thorough  antiseptic  treatment  of  the  skin.  If  this  be 
true,  it  would  seem  that  the  cutaneous  manifestation  of 
the  disease  is  essentially  a  vesicular  eruption,  and  only 
accidentally  becomes  pustular.  Abscesses  are  the  com- 
monest complication  met  with  ;  erysipelas  and  cellulitis 
are  by  no  means  rare.  The  ocular  affections  (keratitis  and 
conjunctivitis)  may  possibly  be  due  to  the  virus  of  the 
original  disease,  but  here  again  the  action  of  secondary 
infections  can  hardly  be  excluded.  Pneumonia,  pleurisy, 
and  empyema  are  also  probably  instances  of  intercurrent 

infection. 

VACCINATION 

Theory  Of  vaccination. — As  already  explained,  vac- 
cination consists  in  inoculation  of  an  attenuated  form  of 
small-pox  germs,  the  diminution  in  virulence  being  brought 
about  by  passage  through  the  body  of  a  calf,  _a  less  suscep- 

1  See  Blaxall:   Thirty-first  Ann.  Kept.  <,f  the.  Mc<l.  Of.  of  11<r  T.oral 
.Gort.  Hoard,  1901-2.     Appendix  C,  i.  oGS. 


184       SERUMS,    VACCINES,    AND    TOXINS 

tible  animal  than  man.  The  attenuated  germs  are  present 
in  the  lymph  of  the  vesicles  formed  on  the  vaccinated  per- 
son, and  this  lymph  may  be  used  for  inoculation  of  other 
individuals,  as  the  germs  do  not  regain  their  virulence  by 
repassage  through  man.  Vaccinia  remains  a  localized  disease, 
the  attenuated  germs  remaining  in  the  place  of  inoculation, 
and  not  becoming  generalized  by  the  blood-stream.  At  the 
point  of  inoculation  they  form  their  toxins,  which  are 
conveyed  all  over  the  body,  and  stimulate  the  tissues  to 
form  germicidal  substances.  The  cells  thus  educated  retain 
the  property  of  secreting  these  substances  for  a  considerable 
length  of  time  ;  in  other  words,  the  person  vaccinated  has 
gained  an  active  immunity  to  small-pox  and  vaccinia. 

Preparation  Of  lymph. — It  is  immaterial,  theoretic, 
ally,  from  what  source,  human  or  bovine,  the  lymph  is 
derived,  but.  for  reasons  set  forth  below,  the  use  of  material 
from  an  "  animal  "  source  is  to  be  preferred  in  practice. 
What  is  known  as  "  glycerinated  calf-lymph  "  is  now  chiefly 
used  in  this  country.1  This  is  prepared  in  the  following 
manner  :  A  supply  of  stock  lymph  being  already  available, 
a  calf  is  taken,  and  its  abdomen  is  shaved.  A  series  of 
parallel  incisions  are  made  in  it  of  considerable  length,  and 
the  stock  lymph  is  rubbed  into  them.  By  the  fifth  day  large 
vesicles  have  developed  along  the  course  of  the  incisions, 
and  are  full  of  clear  fluid  which  does  not  yet  exhibit  any 
tendency  to  become  pustular.  At  this  stage  the  vesicles  and 
their  contents  are  scraped  off  with  a  sterile  sharp  spoon, 
with  all  aseptic  precautions,  and  the  resulting  material  is 
collected  in  suitable  bottles.  It  is  next  finely  broken  up, 
and  triturated  with  four  times  its  weight  of  glycerin  and 
water  (50-per-cent.  solution).  The  thick  creamy  fluid  pro- 
duced is  run  into  tubes,  and  these  are  kept  in  a  cold,  dark 
place  for  some  weeks.  The  yesult  of  this  treatment  is  to 
kill  off  most  of  the  common  pyogenic  and  similar  organisms 
which  might  do  harm  if  inoculated;  even  so  but  few 

1  In  India,  in  addition  to  glycerinated  lymph,  mixtures  with  vase- 
line and  with  lanoline  are  also  employed,  apparently  with  good  results. 


PREPARATION   OF   VACCINE    LYMPH     185 

specimens  of  lymph  are  actually  free  from  extraneous 
bacteria.  The  contagium  of  vaccinia  is  left  apparently 
uninjured.  It  is  possible  that  it  exists  at  this  stage  in 
the  form  of  spores,  which  are  resistant  to  the  action  of 
the  glycerin.  After  about  a  month  the  lymph  is  ex- 
amined bacteriologically,  to  ascertain  whether  it  is  free  from 
gross  bacterial  contamination  ;  and  if  it  is  found  to  be 
innocuous,  it  is  drawn  into  capillary  tubes  and  is  ready  for 
use.  The  lymph  thus  prepared  is  a  thick,  syrupy  fluid, 
which  tends  to  separate  to  some  extent  into  a  clear  and  an 
opaque  portion.  It  is  probable  that  the  latter  is  the  active 
part,  and  care  should  therefore  be  taken  not  to  use  only  the 
clear  portion  in  vaccinating. 

"  Chloroform  "  calf-lymph,  first  introduced  by  Green,1  is 
also  extensively  used  in  England  at  the  present  time.  This 
is  prepared  as  follows :  The  lymph  is  first  mixed  with 
water  for  the  purpose  of  this  procedure.  Air  charged  with 
the  vapour  of  chloroform  is  then  made  to  pass  through  a 
series  of  tubes  of  vaccine,  and  the  chloroform  is  subse- 
quently expelled  from  the  tubes  by  means  of  a  current  of 
air ;  thus  only  the  proportion  of  chloroform  which  the 
water  can  hold  in  solution  (1  :  400)  can  come  in  contact 
with  the  vaccine.  This  quantity  suffices  to  kill  the  bac- 
teria (chiefly  staphylococci)  generally  present,  but  has  no 
ill  effect  on  the  vaccine  virus.  The  addition  to  this  of  any 
traces  of  liquid  chloroform  appears,  however,  to  diminish 
its  activity.  The  advantages  claimed  for  this  method  are 
the  efficiency  and  the  speed  with  which  the  destruction  of 
bacteria  is  effected,  so  that  in  cases  of  emergency  large  quan- 
tities of  vaccine  can  be  rapidly  rendered  fit  for  use,  and 
the  consequent  avoidance  of  any  possible  deterioration  of 
strength,  such  as  may  perhaps  occur  during  the  month  or 
more  for  which  ordinary  glycerinated  lymph  has  to  stand. 

Technique  of  vaccination. — The  essential  point  in 
the  process  of  vaccination  is  that  the  infective  material — 
the  lymph — should  be  introduced  through  the  epidermis,  so 
1  Lancet,  1903,  i.  1738. 


186       SERUMS,   VACCINES,    AND   TOXINS 

as  to  be  absorbed  by  the  lymphatics  and  blood-vessels  of 
the  corium.  The  operation  itself  is  earned  out  in  the  fol- 
lowing manner :  The  Kite  usually  chosen  is  the  skin  of  the 
outer  side  of  the  upper  arm  over  the  insertion  of  the  tendon 
of  the  deltoid  muscle ;  sometimes,  in  females,  on  the  outer 
side  of  the  thigh  just  below  the  great  trochanter,  or  well 
above  the  knee  on  the  inner  or  outer  aspect  of  the  thigh. 
The  skin  at  the  seat  of  operation  is,  if  hairy,  carefully 
shaved,  and,  in  any  case,  well  washed  with  soap  and  water 
and  then  thoroughly  scrubbed  with  ether.  After  the  ether 
has  evaporated,  a  tube  of  lymph  is  opened,  and  the  whole 
of  its  contents  ejected  on  to  the  clean  skin  by  means  of  a 
rubber  bulb  provided  with  a  plug  of  sterilized  cotton-wool ; 
a  sterile  lancet  or  scarifying  needle  is  used  to  scratch  the 
epidermis  through  the  lymph,  care  being  exercised  to  avoid 
drawing  blood  :  the  lymph  is  then  rubbed  into  the  scratches. 
The  superfluous  lymph  is  collected  on  the  blade  of  the  lancet 
and  transferred  to  another  spot  on  the  skin  about  an  inch 
distant,  and  the  process  is  repeated.  Three  or  four  "  inser- 
tions "  are  usually  made,  to  obviate  risk  of  failure.  The 
several  sites  of  inoculation  should  not  be  too  close  together 
— preferably  an  inch  or  an  inch  and  a  half  should  be  left 
between  them — in  order  that  the  resulting  vesicles  may 
not  coalesce.  Should  they  do  so,  an  unduly  sore  arm  may 
ensue,  and  a  considerable  amount  of  scarring  be  finally  left. 
The  lymph  is  left  for  a  few  minutes  to  soak  in,  and  the 
remainder  is  wiped  off  the  skin  with  sterile  cotton-wool. 
The  wounds  are  then  dressed  with  dry  sterile  gauze, 
bandaged  on,  or  a  thin  layer  of  collodium  flexile  is  painted 
over  the  scarifications. 

Nobl l  has  made  trial  of  subcutaneous  injection  of  vaccine- 
lymph  in  doses  of  O'l  to  O2  c.c.,  diluted  with  normal  saline 
solution.  He  finds  that  there  is  less  local  reaction,  and  no 
greater  constitutional  disturbance  than  with  the  ordinary 
method.  Immunity  is  rather  later  in  appeai-ing  (tenth  day). 
Nobl  believes  that  the  method  will  prove  useful  iit  that  it 
1  Wien.  kiln.  n~<><-/<  ,  Aug.  9,  1906. 


PHENOMENA   OF   VACCINATION          187 

avoids  risk  of  local  infection  and  of  auto-inoculation ;   the 
dose,  too,  can  be  exactly  measured,  and  no  scars  result. 

Phenomena  Of  vaccination. — When  properly  per- 
formed, with  that  careful  attention  to  detail  that  should 
characterize  every  bacteriological  procedure,  whether  carried 
out  in  the  laboratory  or  on  the  operating-table  of  the 
surgeon,  vaccination  results,  in  from  five  to  eight  days, 
in  the  formation  of  a  small  vesicle  with  a  sharply  raised 
edge,  filled  with  clear  serum,  and  surrounded  by  a  narrow 
red  areola.  During  the  next  few  days  the  centre  of  the 
vesicle  sinks  so  as  to  form  a  cup-shaped  depression,  and 
the  fluid  contents  of  the  surrounding  portion  of  the  vesicle 
become  white  and  opaque.  By  the  tenth  to  the  twelfth  day 
the  vesicle  has  become  a  dry  scab,  which  finally  separates 
and  leaves  a  circular  depressed  scar — "  foveated." 

About  the  third  day  marked  constitutional  disturbance 
is  noted — rise  of  temperature,  headache  and  general  malaise, 
and  occasionally  sickness  and  diarrho3a,  usually  accompanied 
by  some  itching  at  the  seat  of  inoculation.  These  symptoms 
are  generally  present  until  the  vesicle  is  well  developed  (eight 
to  ten  days),  after  which  they  gradually  subside.  The  neigh- 
bouring lymphatic  glands  are  enlarged  and  tender,  from  about 
the  fifth  to  the  tenth  or  twelfth  day.  The  "  beautiful  arm  " 
so  commonly  seen  after  vaccination  in  the  past  century,  with 
its  vesicles  rapidly  becoming  pustular,  and  the  accompany- 
ing extensive  and  severe  cellulitis,  often  reaching  to  the 
wrist  and  hand,  was  no  criterion  of  efficient  vaccination : 
it  merely  formed  a  pointed  commentary  upon  the  contami- 
nated lymph  and  septic  methods  of  that  age. 

RevaCCinatlOn. — In  those  who  have  already  been  once 
or  more  vaccinated  the  phenomena  are  similar,  but  less 
marked.  Only  a  papule  may  appear,  or  a  poorly  developed 
vesicle  with  subsequent  scabbing.  Itching  may  be  the  most 
marked  feature.  Not  very  infrequently  in  such  persons 
revaccination  fails  entirely. 

Number  of  insertions. — Statistics  prove  that  the  pro- 
tection afforded  by  primary  vaccination  is  to  some  extent 


188       SERUMS,    VACCINES,    AND    TOXINS 

proportional  to  the  number  of  spots  at  which  the  lymph  its 
inserted,  two  "  scars "  protecting  better  than  one,  three 
than  two,  and  four  than  three.  The  practice  of  making 
only  one  insertion  is  to  be  condemned  as  inefficient  and 
conveying  a  false  security.  The  scars  resulting  from  the 
vaccination  should  together  make  up  an  area  of  not  less 
than  half  a  square  inch.  The  following  table  gives  an 
example  of  the  statistical  evidence  upon  which  these  state- 
ments are  founded. 

TABLE  SHOWING  THE  AGE-INCIDENCE  IN  VACCINATED  CASES 
CLASSIFIED  ACCORDING  TO  THE  CHARACTER  OF  THE  ScAKf  :  EACH 
CLASS  IS  REl'KElSENTBU  AS  COMPRISING  A  ToTAL  Oi  1,000  CASES 
(SANDILANDS)  ' 


Character  of  scar 

Under 
10  years 

10- 

20- 

30- 

40- 

50  and 
upwards 

Large  (A  1)  

15 

187 

411 

253 

98 

36 

Medium  (A  2)      ... 

22 

Kill       248 

268 

222 

131 

Small  (A  3)  

45          112       19!) 

241 

211 

192 

Four  or  more 

23 

217 

441 

207 

77 

35 

Three     

11 

148 

350 

309 

127 

55 

Two       

15 

114 

273 

292 

190 

116 

One        

31           12!t 

270 

236 

203 

131 

Half  or  more  than  } 
half  foveated    .  .  .  j 

21           188 

418 

24G 

99 

ft 

Less      than      half  ) 
foveated    \ 

15 

183 

387 

263 

107 

4:, 

Plain  scars   ...     ,\. 

27 

127 

293 

238 

182 

133 

Scars  absent  

83 

204 

210 

157 

127 

219 

Dr.  Sandilands  points  out  that  "the  figures  in  this  table  demon- 
strate a  point  of  some  importance — that  the  incidence  in  Liter  lift- 
is  very  much  greater  in  the  classes  with  inferior  vaccination  scars." 
This  point  is  well  brought  out  in  the  last  column,  where  it  will  be  seen 
that  those  cases  exhibiting  the  depressed  scar  typical  of  a  successful 
vaccination  have  a  case-incidence  of  less  than  3  per  cent.,  whilst 
among  those  showing  the  plain  scar,  resulting  from  infection  with 
pyogenic  organisms  only,  the  incidence  is  five  times  as  great. 


1  "  An  Analysis  of  the  Vaccination  Statistics  of  the  Metropolitan 
Asylums  Board  for  1901  and  1902,"  Lancet,  1903,  ii.  378. 


THEORY   OF    VACCINATION  189 

It  seems  at  first  sight  rather  ditiieult  to  understand  the 
reason  for  the  relation  borne  by  the  amount  of  protection 
to  the  area  of  vesicles  resulting,  since  it  might  be  suppos.ed 
that,  vaccinia  being  an  infective  disease,  the  virus  would 
multiply  in  the  body  in  any  case  to  an  extent  only  limited 
by  the  resistance  of  the  individual,  and  that  therefore  one 
insertion  would  be  as  effective  in  producing  immunity  as 
many.  The  facts  being  as  stated,  it  seems  that  the  infective 
organism,  whatever  its  nature,  remains  localized,  in  the 
majority  of  instances  at  any  rate,  within  the  tissues  near 
the  site  of  inoculation,  multiplying  to  some  extent  therein, 
and  producing  poisons  which  are  carried  throughout  the 
system.  It  would  thus  bear  a  close  resemblance  to  the 
bacilli  of  diphtheria  and  tetanus  in  its  mode  of  behaviour. 
It  is  requisite  that  a  certain  amount  of  the  poison  should 
be  manufactured,  in  order  to  cause  a  sufficient  action  on 
the  cells  of  the  body  to  stimulate  the  formation  of  the 
necessary  amount  of  protective  substances.  Hence  the  need 
for  a  considerable  quantity  of  the  virus  to  be  inoculated, 
the  size  of  the  dose  being  gauged  by  the  number  of  scars, 
since  possibly  the  organisms  tend  to  die  out  somewhat 
rapidly,  being  ex  hypothesi  of  an  attenuated  kind.  It 
seems  not  impossible  that  a  fallacy  of  observation  may 
lurk  in  the  inference  drawn  from  the  statistics,  since  it 
must  be  recollected  that  the  relationship  of  scar-area  to 
immunity  was  predicated  in  the  days  of  septic  lymph  and 
haphazard  technique.  It  may  well  be  that  one  aseptic 
successful  insertion  will  ultimately  prove  to  be  as  protective 
as  the  four  hitherto  insisted  upon  as  the  counsel  of  per- 
fection ;  and  that  it  is  not  so  much  the  number  of  inser- 
tions of  the  lymph  that  protects,  as  the  careful  performance 
of  the  act  of  vaccination,  of  which  the  number  of  scars  is 
some  criterion. 

It  is  well  to  remember  that  the  lymph  remaining  on  the 
arm  or  other  part  vaccinated  may  be  conveyed  accidentally 
to  other  regions  of  the  body,  and  that  if  there  is  any  excoria- 
tion at  the  point  of  contact  a  vaccination  lesion  will  result. 


190       SERUMS,   VACCINES,    AND   TOXINS 

Should  such  an  occurrence  take  place  on  the  face,  a  some- 
what alarming  condition  is  often  produced,  the  affected  part 
swelling  markedly  and  the  neighbouring  glands  enlarging 
to  a  considerable  size.1  The  condition  is  in  no  way  dan- 
gerous, but  an  unsightly  scar  may  be  left.  A  generalized 
eruption  is  sometimes  produced  by  such  accidental  inocula- 
tion if  it  occur  in  several  places. 

Risks  Of  vaccination. — In  the  days  when  it  was  the 
practice  to  vaccinate  one  child  from  another  by  the  "  arm- 
to-arm  "  method,  there  was  a  certain  element  of  risk  lest 
some  disease  should  be  transferred  from  one  to  the  other 
at  the  same  time.  Thus  it  can  hardly  be  denied  that 
syphilis  has  been  conveyed  in  this  manner;  it  seems 
definitely  established  that  the  clear  lymph  of  a  vesicle 
may  convey  the  infection,  even  apart  from  contamination 
with  blood,  and  the  possibility  of  the  transference  becomes 
obvious  since  the  demonstration  of  spirochsetes  in  the 
congenital  syphilitic.  This  risk  no  longer  exists  when  calf- 
lymph  is  used. 

Secondary  infection  may  take  place  at  the  site  of  a 
vaccination  puncture,  as  it  may  by  any  other  abrasion  of 
the  skin.  Thus,  in  a  certain  number  of  cases,  erysipelas  has 
supervened,  owing  to  the  subsequent  entry  of  streptococci 
derived  from  the  insanitary  surroundings  of  the  child.  It 
is  said  that  the  vaccination  in  such  cases  is  generally  un- 
successful. Milder  septic  infection  (probably  with  staphy- 
lococci)  may  result  in  a  sore  arm  of  unusual  severity,  and 
even  give  rise  to  glandular  abscesses. 

In  countries  where  tetaniis  is  common,  this  complication 
has  followed  vaccination.  MacFarland,2  from  a  study  of 
95  such  cases,  concludes  that,  although  such  infection  has 
most  often  been  due  to  subsequent  contamination  of  the 
vaccinated  area,  in  some  cases  the  actual  lymph  may  have 

1  The  picture  thus  presented  has  on  more  than  one  occasion  been 
regarded  as  due  to  infection  by  B.  anthracis,  and  heroic  measures  of 
treatment,  such  as  excision,  have  been  adopted. 

2  Journ.  of  Med.  Research,  Slav,  1902. 


RISKS    OF   VACCINATION  191 

contained  tetanus  spores  derived  from  hay,  manure,  etc. 
Scott1  records  two  cases  of  tetanus  among  30,000  persons 
vaccinated  in  St.  Louis. 

The  constitutional  disturbance  produced  by  vaccina- 
tion may  in  some  cases  be  prolonged,  taking  the  form  of 
somewhat  severe  ancemia.  Bellotti,2  who  calls  attention  to 
this  possible  sequel,  states  that  children  who  have  been 
previously  rosy  and  healthy  in  appearance  most  often 
exhibit  this  condition.  He  suggests  that  the  organisms  of 
vaccinia  may  in  these  rare  cases  exert  a  special  hoemolytic 
action. 

The  names  vaccinia  hcemorrliagica  and  vaccinia  gan- 
grcenosa  have  been  applied  to  conditions  in  which  symptoms 
of  unusual  severity  attend  vaccination.  In  the  former  a 
generalized  hsemorrhagic  eruption  develops,  which  may  be 
accompanied  by  bleeding  from  mucous  surfaces ;  in  the 
latter  the  local  lesions,  instead  of  healing,  extend  deeply 
and  widely,  causing  necrosis  of  the  tissues  and  large 
areas  of  ulceration,  together  with  severe  constitutional 
disturbance. 

It  is  probable  that  these  conditions  are  both  dependent 
in  the  first  place  upon  a  debilitated  condition  of  the  child, 
produced  by  ill  feeding,  rickets,  or  tuberculosis ;  and  in 
the  second  place  upon  an  invasion  by  other  organisms,  such 
as  pyogenic  cocci,  which  either  produce  local  gangrene  in 
the  weakened  tissues,  or  give  rise  to  a  general  septicsemic 
condition,  with  hsemorrhagic  symptoms.  Of  the  close 
connection  between  hfemorrhagic  eruptions  and  general 
septicfemic  states  there  can  be  no  doubt  whatever. 

In  a  third  extremely  rare  condition,  known  as  gener- 
alized vaccinia,  successive  crops  of  vesicles  develop  upon 
various  parts  of  the  body  and  upon  the  mucous  membranes 
of  the  mouth,  nose,  eye,  and  genitals,  at  short  intervals, 
until  in  severe  cases  only  a  few  small  areas  of  normal  skin 
remain.  It  may  be  due  on  the  one  hand  to  extreme 

1  Medical  Record,  1910,  Ixxviii.  811. 
-  Gaz.  degli  Ospedali,  May  10,  1903. 


I!'-'       SERUMS,    VACCINES,   AND    TOXINS 

viruleuce    of   the   germs    inoculated,   or    on    the    other    to 
extreme  susceptibility  of  the  vaccinated  individual. 

A  cheloid  condition  sometimes  results  from  the  scarring 
produced  in  vaccination.  This  probably  has  nothing  to 
do  with  the  virus  employed,  but  depends  upon  a  constitu- 
tional peculiarity  of  the  individual,  in  whom  any  slight 
traumatism  may  give  rise  to  a  chronic  inflammatory  over- 
production of  scar-tissue. 

In  the  absence  of  an  epidemic  of  small-pox  a  child  should 
not  be  vaccinated  when  it  is  obviously  in  bad  health.  Not 
only  will  the  parents  attribute  to  the  operation  any  in- 
crease in  the  symptoms  of  the  existing  condition  which  may 
ensue,  however  accidentally — so  that  the  procedure  will 
incur  some  degree,  of  disrepute  with  them  and  with  their 
ignorant  neighbours,  which  it  is  better  to  avoid — but  it  is 
probable  that  in  some  instances  the  constitutional  disturb- 
ance produced  by  the  inoculation  may  unduly  depress  a 
child  already  weakened  by  existing  disease.  Children 
suffering  from  eczema,  herpes,  or  other  skin-disease  should 
not  be  vaccinated,  if  the  matter  is  not  urgent.  Generaliza- 
tion of  the  vaccinial  eruption  is  said  to  occur  in  such 
patients,  but  the  evidence  is  not  very  clear.  Hjemophilic 
subjects  should  either  not  be  vaccinated,  the  risk  to  them 
being  greater  from  any  source  of  bleeding  than  from  the 
continued  liability  to  small-pox ;  or  they  should  have  the 
lymph  introduced  by  subcutaneous  injection. 

Insusceptibility  to  vaccination.— It  is  said  that 
some  persons  are  by  nature  insusceptible  to  vaccination. 
This  may  possibly  be  the  case  occasionally,  but  instances 
of  such  a  condition  which  will  stand  investigation  must 
be  very  rare  indeed.  Thus,  Thorne  l  states  that  107,180 
vaccinations  have  been  done  by  public  vaccinators  under 
the  Local  Government  Board  without  one  instance  of 
failure.  Cory 2  reports  one  case,  among  38,000,  in  which 

1  Twenty-seventh  Ann.  Sept.  of  the  Ned.  Off.  of  the  Local   Gort. 
Board,  p.  viii. 

2  "Lectures  on  Vaccination,"  p.  73. 


PROTECTION   BY   VACCINATION          193 

he  was  twice  unsuccessful  in  attempting  to  vaccinate  an 
infant.  Bryce  l  records  98  unsuccessful  attempts  to  vacci- 
nate with  calf -lymph  out  of  126,000  vaccinations.  Accord- 
ing to  English  law,  it  is  necessary  to  make  three  attempts 
at  (primary)  vaccination  before  pronouncing  any  individual 
insusceptible.  It  is  not  unusual,  in  attempting  to  revac- 
cinate  an  adult,  to  find  it  impossible  to  produce  any  effect 
recognizable  as  vaccinia.  The  same  is  of  course  true,  and 
to  a  still  greater  degree,  of  those  who  have  suffered  from 
small-pox. 

Supply  of  lymph. — In  the  present  state  of  the  law 
in  this  country,  public  vaccinators  are  supplied  by  the 
Local  Government  Board  with  lymph  which  is  prepared 
under  careful  State  supervision.  This  lymph  is  not  to  be 
obtained  by  other  practitioners,  who  are  dependent  for  their 
material  upon  the  lymph  offered  in  the  market  by  private 
trading  establishments.  No  supervision  of  any  kind  is 
exercised  over  these  manufactories,  so  that  only  the  pressure 
of  competition  with  other  firms,  and  the  risk  of  losing 
custom  if  their  product  is  found  inert,  are  to  be  relied  upon 
to  ensiire  the  purity  and  efficacy  of  these  lymphs.  Such  a 
state  of  things  appears  entirely  indefensible.  It  is  much  to 
be  hoped  that,  in  future  Acts  of  Parliament  dealing  with 
vaccination,  provision  will  be  made  for  the  inspection  of 
private  vaccine  establishments,  and  for  the  testing  by  State 
officials  of  all  lymph  put  upon  the  market,  with  regard  to 
its  activity,  and  also  to  its  freedom  from  bacterial  contami- 
nation. Although  eleven  years  have  elapsed  since  the  issue 
of  the  first  edition  of  this  book,  no  step  has  yet  been  taken 
in  this  direction. 

Protection  afforded  by  vaccination.— Of  the  value 

of  the  protection  afforded  by  vaccination  against  small-pox 
there  can  be  no  doubt  in  the  mind  of  anyone  who  is  willing 
to  look  facts  in  the  face  and  draw  conclusions  without 
pre-existing  bias.  Before  Jenner  introduced  his  great  dis- 
covery to  the  world  the  disease  was  universally  prevalent. 

1  Boston  Med.  and  Surg.  Journ.,  Feb.  26,  1903. 
N 


194       SERUMS,    VACCINES,    AND    TOXINS 

It  was  regarded  as  a  children's  disease,  owing  to  the  fact  that 
all  were  susceptible  and  contracted  small-pox  at  the  earliest 
opportunity.  It  thus  caused  an  immense  infantile  mortality  ; 
but  it  also  attacked  adults  of  all  ages  and  all  positions  in 
life.  Princes  were  no  more  sacred  from  its  attack  than  the 
poor  ;  scarred  faces  were  the  rule  rather  than  the  exception. 
Hence  the  new  prophylactic  was  welcomed  with  delight 
throughout  the  world,  and  special  measures  wore  taken  to 
introduce  it  and  to  carry  a  supply  of  lymph  into  the  most 
distant  countries. 

At  the  present  day,  owing  to  the  general  practice  of 
vaccination,  small-pox1  is  a  rare  disease,  and  its  very  rarity 
has  caused  a  certain  degree  of  carelessness  in  carrying  out 
the  prophylactic  procedure.  Hence  there  are  signs  that  in 
this  country  the  disease  is  making  attempts  to  re-assert 
itself;  and  places  such  as  Gloucester  and  Leicester,  where 
the  fanatical  opponents  of  vaccination  have  gained  the 
ascendancy  and  succeeded  in  causing  general  neglect  of  the 
precaution,  have  paid  the  penalty  for  their  folly  by  suffering 
from  severe  epidemics. 

The  general  recognition  of  the  value  of  vaccination  is 
shown  in  the  regulations  adopted  by  most  life-insurance 
offices,  which  charge  an  additional  premium  to  all  those  who 
have  not  been  vaccinated.  In  view  of  the  general  protection 
of  the  community,  the  risk  is  small  and  the  addition  slight ; 
but  there  can  be  no  doubt  that,  if  small-pox  once  more 
became  prevalent,  this  additional  percentage  would  be  con- 
siderably increased.  Vaccination,  or  revaccination,  is  also 
compulsory  upon  recruits  for  the  army  and  navy,  and  upon 
those  employed  in  the  postal  service. 

The  statistics  of  the  German  army  and  of  the  civil 
population l  in  that  country  afford  convincing  evidence  of 
the  benefits  derived  from  vaccination,  if  any  be  still  needed. 
When  compulsory  vaccination  was  introduced  into  the 
army  the  average  deaths  per  100,000  (taking  an  average 

1  See   Statistical    Chart    quoted    in    Marx,    "  Die    Experimental 
Diagnostik,  Serumtherapie  u.  Prophylaxe  der  Infectionskrankh.,"  1907. 


STATISTICS   OF  VACCINATION  195 

of  the  10  years  before  and  the  10  years  after  its  initiation) 
fell  from  36  to  3,  whereas  in  the  civil  population,  not  thus 
protected,  the  relative  numbers  i-emained  26-9  and  19-4 
respectively,  showing  no  such  tendency  to  fall.  At  the  same 
time  the  existence  of  small-pox  among  the  civil  population 
was  a  source  of  infection  even  to  the  protected  members 
of  the  army,  a  small  number  of  cases  continuing  to  occur. 
It  was  only  after  vaccination  was  enforced  universally 
throughout  Germany  that  the  disease  practically  disappeared 
from  the  army,  while  among  the  civil  population  also  it  at 
once  fell  almost  to  vanishing-point. 

We  may  prove  the  value  of  the  protection  thus  afforded 
by  vaccination,  by  means  of  a  comparison  of  the  German 
army  with  others  not  so  protected.  In  the  German  army, 
from  1875  to  1887,  only  148  cases  of  small-pox  occurred 
whereas  in  the  Austrian  army,  not  protected  by  systematic 
vaccination,  there  were  10,238  cases  between  1873  and 
1886,  and  in  the  French  army,  from  1875  to  1881,  5,605 
attacks.1  In  Sweden,  in  prevaccination  days,  2,050  deaths 
occurred  annually  from  variola  ;  after  vaccination  was  intro- 
duced the  average  mortality  fell  to  169  per  annum.  In 
Bohemia,  with  a  population  of  3,039,722,  the  average 
annual  deaths  from  small-pox  were  7,663  ;  after  vaccina- 
tion was  introduced  they  fell  to  282,  though  the  population 
had  risen  meanwhile  to  4,248,155.  Thus  the  small-pox 
mortality  fell,  owing  to  vaccination,  from  1  in  397  of 
the  population  to  1  in  14,741 — a  sufficiently  striking 
decrease. 

There  is  no  doubt  that  Jenner  was  wrong  in  con- 
sidering that  vaccination  once  performed  conferred  an 
absolute  immunity  against  small-pox ;  and  failure  to  re- 
cognize certain,  limitations  in  this  respect  has  done 
harm,  by  enabling  disbelievers  in  the  practice  to  create 
a  distrust  in  the  minds  of  the  ignorant  by  pointing  to 
individual  instances  of  failure,  where  complete  protection 

1  Immermann,  art.  "Vaccination"  in  Nothnagel's  "  Encycl,  of 
Tract.  Med.,"  English  ed.,  1902. 


196       SERUMS,   VACCINES,    AND   TOXINS 


had  been  promised.  That  a  person  who  has  been  once 
vaccinated  may  afterwards  suffer  from  small-pox  is  un- 
doubted, although  it  is  almost  always  the  case  that  a 
subsequent  attack  of  the  disease,  if  it  should  occur,  is 
relatively  mild  (modified  small-pox).  A  certain  number  of 
deaths  do,  however,  occur  even  among  those  who  have  been 
vaccinated.  Even  revaccination  does  not  necessarily  confer 
absolute  immunity. 

The  explanation  of  this  is  not  difficult.  In  the  first 
place,  there  19  now  no  doubt  that  in  many  persons 
the  period  of  immunity  after  vaccination  is  not  indefi- 
nitely prolonged.  Perhaps  seven  years  may  be  taken  as 
the  average  period  of  fairly  complete  protection,  but 
probably  even  during  this  time  the  degree  of  resistance 
is  constantly  diminishing.  In  the  second  place,  it  is  most 
probable  that  modifications  of  general  health  may  affect 
the  individual's  resistance  to  this,  as  to  other  diseases, 
even  when  immunity  has  been  produced.  Fatigue  or  ill- 
health  may  perhaps  temporarily  reduce  the  powers  of 
defence.  The  longer,  therefore,  the  period  which  has 
elapsed  after  vaccination,  the  less  the  degree  of  protection 
that  is  likely  to  persist,  and  the  more  easily  will  depressing 
circumstances  suffice  to  reduce  it  below  the  point  necessary 
to  confer  immunity.  The  following  tablo  shows  the  gra- 
dually diminishing  protection  afforded  by  vaccination,  and 
the  consequent  increase  of  mortality  as  age  advances  : — 

TABLE  SHOWING  THE  PERCENTAGE  MORTALITY  AT  SEVERAL  AGE- 
PERIODS  AMONG  THE  SAME  ScAR-BEARIXG  VACCINATED  CASES 
AS  ARE  SHOWN  IN  THE  FORMER  TABLE,  p.  188  (&ANDILAND)  1 


Under 

70  and 

10 

111- 

20-       30- 

to. 

50- 

60- 

upward* 

years 

Mortality 

3         2       7        ', 

22 

21 

24 

20 

1  Op.  supra  cit. 


NEED    FOR   REVACCINATION  197 

Hence  it  cannot  be  too  strongly  insisted  upon  that  not 
only  vaccination,  but  revaccination,  is  needful  to  protect 
the  individual  and  society  against  small-pox.  Children 
should  not  only  be  vaccinated  soon  after  birth — within  the 
first  three  months  of  life — but  revaccinated,  perhaps  on 
going  to  school,  and  certainly  on  leaving  it.  Should  small- 
pox be  at  all  prevalent,  adults  will  be  wise  to  have  the 
operation  repeated  if  more  than  seven  years  have  elapsed 
since  they  last  underwent  it.  If  as  a  matter  of  fact  they 
are  still  immune,  the  vaccination  will  not  "  take,"  and  they 
will  suffer  no  inconvenience ;  while  if  it  succeed,  they  will 
have  the  satisfaction  of  knowing  that  they  have  gained  a 
new  lease  of  immunity. 

In  this  connection  we  may  quote  the  following  remarks 
by  Dr.  Sandiland  l  with  regard  to  the  protection  of  the 
community  at  large  by  vaccination  : — 

"  It  cannot  be  too  much  emphasized  that  the  extraordinary 
diminution  in  the  mortality  from  small-pox  in  the  last  century  has 
been  due,  not  so  much  to  the  protection  of  a  majority  of  the  population, 
as  to  the  absolute  immunity  of  a  minority,  probably  made  up  from 
persons  at  all  periods  of  life,  who  are  continually  standing  in  the  way 
of  small-pox  infection,  and  compelling  it  to  travel  by  long  and  cir- 
cuitous routes  before  alighting,  scattered  and  diluted,  on  patches  of 
soil  in  which  it  can  take  root  and  flourish. 

"  Again,  a  person  saved  from  small-pox  by  vaccination  should  not, 
so  to  speak,  be  counted  as  one,  but  rather  should  be  represented  by  a 
figure  standing  for  himself  and  all  those  whom  he  would  have  infected 
had  lie  been  overtaken  by  the  disease.  It  is  this  process  of  the  multi- 
plication of  the  benefits  of  vaccination  which  has  reduced  the  small- 
pox mortality  in  England  out  of  all  proportion  to  the  protective  power 
of  infantile  vaccination,  and  which  makes  it  reasonable  to  anticipate 
with  confidence  that  if  re  vaccination  in  adolescence  were  added  to 
infantile  vaccination,  small-pox  would  disappear,  as  indeed  it  has 
disappeared  in  Germany." 

Rapidity  of  protection  gained.— With  regard  to  the 

exact  period  at  which  immunity  to  small-pox  is  produced 
by  vaccination — i.e.  on  which   day  after  the  performance 

1  St.  Bartholomew's  Hosp.  Journ.,  July,  1903,  p.  155. 


198       SERUMS,    VACCINES,    AND    TOXINS 

of  the  inoculation — it  is  difficult  to  be  certain.  No  doubt 
the  immunity  is  a  gradually  increasing  one,  but  it  is  prob- 
ably slight  before  the  vesicles  are  well  developed,  and  is 
mainly  brought  about  from  this  period  to  the  time  when 
they  become  purulent.  According  to  Bryce.1  protection  is 
complete  by  the  fourth  day  after  vaccination,  and  only  a 
modified  small-pox  is  likely  to  ensue  in  cases  in  which 
exposure  to  infection  is  contemporaneous  with  vaccination, 
a  fatal  issue  being  improbable  in  such  a  case.  It  will  be 
remembered  that  the  incubation  period  of  small-pox  is 
usually  about  twelve  days,  so  that  vaccinia  will  have  time 
to  develop  to  its  full  extent  in  the  interval  between 
infection  and  the  onset  of  symptoms.  According  to 
E.  Hart,2  immunity  reaches  its  maximum  about  the 
fourth  week  after  vaccination.  There  is  little  doubt  that 
individuals  vary  as  to  the  rapidity  with  winch  protec- 
tion is  gained,  as  well  as  with  regard  to  the  length  of 
time  for  which  it  remains.  The  "  memory "  of  tissue- 
cells  with  regard  to  the  production  of  immunizing  sub- 
stances is  as  liable  to  vary  as  the  mental  memory  for 
events. 

Modified  small-pOX. — Small-pox  occurring  in  persons 
who  have  been  vaccinated  is  generally  of  the  kind  known 
as  "  modified  "  small-pox.  The  eruption  is  usually  scanty 
and  comes  out  rapidly,  becoming  vesicular  within  twelve  to 
twenty-four  hours.  Some  of  the  papules  may  never  develop 
into  vesicles.  The  vesicles  which  do  form  are  often  smaller 
than  those  seen  in  the  unmodified  disease,  and  many  of 
them  dry  up  without  becoming  pustular.  The  crusts  fall  off 
more  rapidly  than  in  ordinary  small-pox,  and  less  pitting 
is  generally  left  behind.  The  constitutional  symptoms  are 
mxich  less  pronounced,  and  often  subside  entirely  within 
two  or  three  days,  the  patient  being  practically  well  within 
a  fortnight  of  the  onset.  Complications  are  infrequent 
and  scarcely  ever  severe. 

1  Boston  Med.  and  Surg.  Journ.,  Feb.  26,  1903. 
-  Allbutt's  "System  of  Medicine,"  1897,  ii.  578. 


SMALL-POX  199 

SERUM    TREATMENT 

Serum  Of  immune  cattle. — Thomson  and  Brownlee 1 
made  experiments  with  regard  to  a  possible  antitoxic 
influence,  upon  patients  suffering  from  small-pox,  of  the 
serum  derived  from  heifers  which  were  immune  to  vaccinia. 
Large  quantities  of  the  serum  were  injected,  but  the  results 
were  apparently  quite  negative.  In  certain  cases  a  modified 
form  of  the  disease  occurred  ;  but,  as  the  patients  had  been 
vaccinated,  it  was  probably  to  be  attributed  to  this 
cause.  The  serum  did  not  appear  to  influence  the  course 
of  vaccination  (revaccination)  in  one  case  in  which  this  was 
done. 

Serum  of  convalescents. — This  has  been  tried  by 

Tessier  and  Marie 3  in  1 3  severe  cases  of  variola,  with  8 
recoveries.  The  doses  administered  were  from  25  c.c.  to 
100  c.c. 

AntistreptOCOCCic  serum. — With  a  view  to  diminish- 
ing complications,  the  use  of  antistreptococcic  serum  has 
been  suggested  (Lindsey).  Schoull 3  has  made  a  practice  of 
injecting  60  c.c.  of  this  serum  in  three  doses  of  20  c.c.,  and 
gives  even  more  than  this  in  severe  cases.  No  pain  or  re- 
action is  induced  by  the  injection,  which  is  given  in  the  flank, 
all  antiseptic  precautions  being  taken.  He  claims  that 
rapid  improvement  results  in  all  the  symptoms  which  are 
connected  with  the  eruption.  The  painful  condition  of 
the  face  subsides ;  photophobia,  dysphagia,  and  hoarseness 
diminish  ;  pruritus  is  checked.  In  some  instances  a  single 
injection  of  the  antistreptococcic  serum  produced  an 
immediate  fall  of  temperature.  Even  hsemorrhagic  cases 
may  recover  under  this  treatment.  In  all  Schoull  treated 
5  hfemorrhagic,  8  confluent,  and  9  discrete  cases.  Out  of 
these,  2  patients  died  (9  per  cent.),  whereas  the  general 

1  Lancet,  1903,  i.  947. 

2  Compt.  Rend.  Acad.  Sci.,  1910,  civ.  1536. 

3  La  Semalne  Med.,  March  11,  1903;  Med.  News,  April  25,  1903, 
p.  794, 


200       SERUMS,    VACCINES,    AND    TOXINS 

mortality  in  cases  not  so  treated  was  20 -5  per  cent. 
Alfred  Smith l  speaks  enthusiastically  of  this  method  of 
treatment,  as  shortening  the  duration  of  the  disease  and 
preventing  pitting  and  complications.  The  serum  should 
be  used  early,  and  in  sufficient  quantities  (20  c.c.,  repeated). 
Salvarsan  has  been  tried  empirically  by  Sunder  2  in  6 
cases  of  small-pox  with  apparent  benefit. 

CONCLUSIONS 

1.  Vaccination    confers    an    active    immunity    against 
small-pox,  and    protects    almost    absolutely  for    a    certain 
period   of  time.     This  immunity  gradually  diminishes,  and 
in  many  cases  disappears  after  a  longer  or  shorter  interval, 
which  varies  in  different  individuals.     The  immunity  may 
be  renewed  by  re  vaccination. 

2.  In    a   person  who  has  been  even   once    vaccinated 
small-pox  generally  occurs,   if 'at  all,  in  a  modified  form, 
which  is  comparatively  seldom  fatal. 

3.  If   aseptic  methods  are  practised    and    calf-lymph, 
duly  sterilized,  used,  the  danger  of  any  ill  effects  resulting 
is  very  small  indeed.     Untoward  results  are  generally  due 
to  want  of  cleanliness  and  lack  of  care  in  the  after-treatment 
of  the  lesions  resulting  from  the  inoculation. 

4.  Complications  in  the  course  of  small-pox  are  gener- 
ally due  to  intercurreiit  infection  with  various  pyogenic 
organisms,   and   there    is    reason   to  believe  that    in    some 
instances  the  use  of  antistreptococcic   serum    may   prove 
beneficial  in  averting  or  modifying  them. 

5.  Attempts  to  treat  the  disease  with  a  serum  derived 
from  immune  cattle  have  been  unsuccessful.     No  antitoxic 
serum  is  known. 

1  Med.  Record,  April  2,  1904,  p.  533. 

-  Arch.  f.  Sc/iifs-  u.  Tropenliyg.,  1912,  xvi.  563, 


CHAPTER  X 
ANTHRAX    AND    GLANDERS 

ANTHRAX 

Causal  agent. — The  Bacillus  anthracis  was  the  earliest 
micro-organism  to  be  discovered,  on  account  of  its  large 
size,  the  discovery  being  made  by  Davaine  in  1850.  The 
organism  had  probably  been  seen  by  Pollender  in  the 
previous  year. 

Of  its  toxins  little  is  known  ;  it  does  not  even  seem 
definitely  settled  whether  it  produces  a  soluble  poison  or 
only  contains  an  intracellular  toxin. 

SERUM   TREATMENT 

Sdavo's  serum. — After  a  long  course  of  experiments, 
Sclavo 1  succeeded  in  immunizing  goats  against  B.  anthracis, 
and  found  that  their  serum  had  a  protective  and  cura- 
tive effect.  The  goats  were  injected  first  with  attenuated 
cultures  of  the  bacilli,  and  afterwards  with  virulent 
organisms.  Rabbits  were  protected  by  the  serum  against 
lethal  doses  of  anthrax  bacilli,  and  the  injection  of  an 
adequate  dose  within  twenty-four  hours  after  infection 
exerted  a  curative  effect.  Great  difficulty  is,  however,  expe- 
rienced in  preparing  a  serum  sufficiently  potent  to  protect 
against  the  more  virulent  strains  of  the  organism.  To 
test  the  value  of  the  serum,  rabbits  are  injected  intra- 
venously with  5  c.c.  of  the  serum,  and  then  receive,  two 
hours  later,  one-tenth  part  of  a  virulent  agar-culture  of 
B.  anthracis. 

More  recently  Sclavo  has  made  use  of  asses  for  the 

1  Berl.  Jtlin.  Wooh.,  1901,  Nos.  18  and  19,  pp.  481,  520, 
201 

.-tut  otr 


202       SERUMS,    VACCINES,    AND    TOXINS 

preparation  of  his  serum.  It  is  found  that  if  2  c.c.  of 
the  serum  thus  obtained  is  injected  into  a  rabbit  along 
with  1  c.c.  of  a  fresh,  virulent  broth-culture  of  bacilli,  the 
animal  is  able  to  survive.  For  use  in  man,  30  to  40  c.c.  is 
injected  in  the  flank,  the  whole  amount  being  divided  and 
injected  in  three  or  four  different  places.  In  severe  cases, 
intravenous  injection  may  be  employed.  The  administration 
of  the  serum  may  be  followed  by  a  rise  of  temperature, 
which  is  of  good  prognostic  import.  Sclavo  considers  that 
his  serum  acts  by  stimulating  the  leucocytes  in  their  conflict 
with  the  germs  ;  in  any  case  it  is  an  antibacterial,  not  an 
antitoxic  serum. 

Very  favourable  results  are  recorded  in  cases  of 
human  anthrax  in  which  Sclavo's  serum  was  used.  Thus, 
Cigognani1  records  the  successful  use  of  this  serum  in  a 
series  of  14  cases.  Large  doses  were  given  without  any 
ill  effects  beyond  the  appearance  of  urticaria.  The  amount 
used  was  40  c.c.,  which  he  found  it  best  to  give  intravenously. 
Good  effects  are  rapidly  produced.  The  general  condition 
improves  in  a  few  hours,  and  the  pustules  heal  up 
within  two  days,  while  convalescence  is  much  shortened. 
Cases  which  appeared  alarmingly  ill  were  cured  by  the  use 
of  the  serum. 

Legge  ~  collected  67  cases  treated  with  this  serum  ;  in  56 
the  serum  was  used  alone.  He  quotes  Sclavo's  statistics 
of  143  cases,  with  a  mortality  of  6  per  cent.,  as  compared 
with  the  average  mortality  of  24  per  cent.  The  serum 
should  be  given  freely.  It  may  be  followed  by  a  sharp 
rise  of  temperature  (104°-105°  F.).  Successful  cases  in 
this  country  are  recorded  by  Lockwood  and  Andrewes,3 
Stretton,4  and  Mitchell.5  Gutfreund6  states  that  the  serum 

1  Gaz.  degli  Ospedali,  1902,  No.  114. 

-  Milroy  Lecture,  Brit.  Med.  Journ.,  1905,  i.  589. 

3  Brit.  Med.  Jonrn.,  1905,  i.  16. 

4  Lancet,  1905,  i.  1420. 

4  Brit.  Med.  Joiirn.,  1905,  ii.  118. 

6  Abstr.  in  Zeitschr.f.  Immunitatsforsch.,  1910,  p.  1087, 


ANTHRAX— GLANDERS  203 

is  valuable  if  it  be  given  intravenously,  but  useless  when 
administered  subcutaneously. 

Mendez'S  serum. —  Mendez1  has  immunized  horses 
by  means  of  injections  extending  over  periods  of  six  to 
eight  months,  and  finds  that  he  obtains  a  useful  serum. 
He  records  that  in  25  cases  in  man  the  injections  were 
followed  by  feeling  of  improvement,  with  fall  of  tempera- 
ture, and  subsidence  of  oedema  and  glandular  swelling. 
The  dose  used  is  20  c.c.,  and  it  is  seldom  necessary  to 
repeat  it.  In  cattle  and  sheep  the  serum  has  a  curative 
effect,  acting  efficiently  even  in  doses  of  0'5  to  1  c.c. 

Deutsch's  serum. — L.  Deutsch3  has  also  prepared  a 
serum.  It  seems  to  be  efficient  for  treatment  of  cattle, 
but  has  not  been  used  upon  man.  It  agglutinates  the 
bacilli  strongly,  and  contains  an  immune  body  or  copula 
capable  of  destroying  the  organisms  in  the  presence  of  a 
suitable  complement. 

Non-specific  treatment. — Bettmann  and  Lauben- 
heimer3  have  used  salvarsan  in  cases  of  anthrax  with 
apparent  benefit. 

Vaccines. — Prophylactic  vaccination  against  anthrax 
has  been  carried  out  in  cattle  on  a  large  scale  with  satis- 
factory results,  but  as  it  does  not  apply  to  human  beings 
it  cannot  be  dealt  with  here. 

GLANDERS 

Causal  agent. — The  Bacillus  mallei  was  discovered  by 
Loeffler  and  Schutz  in  1 882.  Although  primarily  a  disease  of 
horses,  man  is  highly  susceptible — on  an  average  4  deaths 
per  annum  are  recorded  in  England  and  Wales — and  when 
attacked  by  the  acute  form  almost  invariably  succumbs. 
Eyre4  states  that  among  245  collected  human  cases, 

1  CentralbL  f.  Sakt.,  1899,  xxvi.,  Nos.  21  and  22. 
-  Deutsch  and  Feistmantel,   "Impfstoffe   und  Sera."     Leipzig, 
1903. 

3  Deut.  med.  Woch.,  1912,  p.  349. 

4  Art.  "  Glanders  "  in  "  Quain's  Dictionary  of  Medicine,"  1902. 


204       SERUMS,    VACCINES,    AND    TOXINS 

including  both  acute  and  chronic  forms,  there  was  a  mor- 
tality of  85  per  cent.  In  a  series  of  chronic  cases  alone 
Bollinger  states  that  50  per  cent,  recovered. 

Toxins. — By  growing  the  bacilli  for  a  month  in  flasks 
of  veal-broth  at  37°  C.,  then  destroying  the  bacteria  by 
heat  and  filtering  the  culture-medium  through  a  porcelain 
filter,  a  solution  of  toxins  comparable  to  old  tuberculin  is 
obtained.  This  is  known  as  mallein,  and  is  employed  in 
the  diagnosis  of  glanders  in  animals,  but  has  no  place 
in  human  medicine. 

Serum. — No  antiserum  has  been  prepared  for  use  in 
this  disease. 

Vaccine  treatment. — Wright1  has  treated  one  case 
of  chronic  glanders  successfully  with  vaccine.  We  have 
treated  one  such  case  with  a  vaccine  prepared  from  the 
patient's  own  bacilli,  with  some  improvement  of  the  local 
lesions,  but  the  mallein  reaction  at  the  site  of  injection 
of  the  vaccine  and  the  rise  of  temperature  were  so  marked 
that  the  patient  soon  refused  to  continue  the  treatment  and 
discharged  himself  from  the  hospital. 

Agglutination  reaction. — As  B.  mallei  is  agglutin- 
ated by  the  serum  of  infected  animals  and  man,  this  re- 
action is  valuable  as  a  test  for  the  presence  of  the  disease. 
The  microscopical  method  of  observing  agglutination,  which 
is  so  reliable  in  the  case  of  enteric  fever,  is,  however,  value- 
less here,  as  the  reaction  is  tardy  and  the  results  are  incon- 
sistent ;  but  with  the  macroscopical  reaction  the  results  are 
quite  trustworthy.  For  this  purpose  various  dilutions  of  the 
suspected  serum  are  made  with  normal  saline  solution  by 
means  of  a  graduated  pipette  ;  a  homogeneous  emulsion  in 
sterile  water,  or  preferably,  on  account  of  the  virulence 
of  the  organism,  in  1  per  cent,  formalin  solution,  of  an 
agar-culture  of  B.  mallei,  twenty-four  hours  old,  is  also  pre- 
pared, and  equal  quantities  of  the  emulsion  and  of  each  of 
the  dilutions  are  mixed  either  in  small  test-tubes  or  taken 
up  in  capillary  pipettes  and  sealed.  Control  preparations 
1  "  Studies  on  Immunization,"  1909,  p.  406. 


GLANDERS  205 

with  1  :  5  and  1  :  10  solution  of  normal  serum  are  like- 
wise put  up  for  comparison.  The  preparations  are  allowed 
to  stand  at  room-temperature  for  twelve  to  eighteen  hours ; 
at  the  end  of  the  time  they  are  examined,  and  those 
dilutions  in  which  complete  sedimentation  of  the  bacilli  has 
taken  place  are  noted.  Normal  serum,  even  in  1  :  5  dilution, 
fails  to  produce  sedimentation  of  the  bacillus,  whilst  the 
serum  of  an  individual  infected  with  glanders  gives  a  good 
reaction  in  1  :  50  dilution,  in  many  cases  in  1  :  100,  and 
sometimes  in  1  :  200  and  even  higher  dilutions. 


CHAPTER    XI 
PLAGUE 

Causal  organism. — The  Bacillus  pestis  was  discovered 
by  Yersin  in  1894.  The  bodies  of  the  bacteria  themselves 
are  highly  toxic,  but  the  organism  does  not  appear  to  form 
virulent  poisons  in  culture-media.  Klein's  experiments, 
however,  seem  to  show  that  some  toxic  material  is  con- 
tained in  the  fluid  of  broth-cultures  of  the  bacilli  (see 
p.  209)  ;  and  Dean,1  who  also  obtained  evidence  of  the 
existence  of  free  toxin  in  old  cultures,  showed  that  it  could 
be  separated  from  the  bacilli  by  nitration.  By  its  action 
as  a  parasite,  the  organism  produces  a  "  hsemorrhagic 
septicaemia,"  that  is  to  say,  a  general  infection  (the  organ- 
isms multiplying  in  the  blood-stream),  with  interstitial 
haemorrhages  in  the  various  organs.  Curative  serums  have 
been  prepared  for  the  treatment  of  the  disease,  and 
protective  vaccination  has  been  carried  out. 

DIAGNOSIS 

Agglutination. — Plague  bacilli,  like  those  of  enteric 
fever  and  many  others,  are  agglutinated  by  the  serum  of 
patients  who  have  just  suffered  from  the  disease,  or  of 
animals  which  have  been  inoculated  with  the  bacilli  or  their 
products.  There  is  some  difficulty  in  performing  the  test 
owing  to  the  normal  occurrence  of  the  bacilli  on  nutrient 
media  in  closely  adherent  masses ;  if,  however,  the  emulsion 
is  made  in  sterile  water  and  well  shaken  with  glass  beads, 

1  ''Studies  in  Pathology,   in  celebration  of  the  Quatercentenarv 
of  the  University  of  Aberdeen,"  1906. 

206 


207 

the  bacilli  become  thoroughly  separated.  Klein  l  advises 
that  they  should  be  grown  on  gelatin,  on  which  a  drier  and 
less  sticky  culture  is  formed,  and  that  they  should  then  be 
suspended  in  salt-solution.  If  it  be  found  that  the  bacilli 
are  still  present  in  clumps  and  not  distributed  singly,  it  is 
better  to  make  a  thick  emulsion  of  -them,  and  to  filter  it 
through  a  double  thickness  of  filter-paper.  The  microscopic 
method  of  examination  must  be  applied,  as  the  naked-eye 
or  "  sedimentation  "  test  is  unreliable.  Emulsions  of  the 
bacilli  in  broth  are  also  to  be  avoided  for  this  test,  as  they 
tend  to  spontaneous  agglutination  without  the  aid  of 
immune  serum.  Klein  recommends  a  dilution  of  1  :  20  for 
use,  and  a  time-limit  of  half  an  hour.  He  finds  that  the 
blood  of  immunized  animals,  though  strongly  agglutinative, 
is  not  bactericidal.  The  growth  of  B.  pestis  is  said  to  be 
retarded  by  addition  of  serum  from  a  plague  convalescent  ; 
this  appears  to  contain  a  bacteriolytic  copula.2 

In  human  patients  the  agglutinative  power  of  the  blood 
does  not  develop  until  late  in  the  disease,  often  not  till 
convalescence  is  established.  The  test  is  therefore  useless 
clinically.  It  may,  however,  be  valuable  as  a  proof  that  a 
specimen  of  bacillus  under  examination  is  B.  pestis. 

HAFFKINE'S    PROPHYLACTIC 

Preparation  Of  vaccine. — Haffkine  prepares  his  vac- 
cine by  growing  B.  pestis  in  flasks  of  broth  to  which  a 
few  drops  of  fat  or  oil  have  been  added.  Each  drop,  as  it 
floats  on  the  surface  of  the  liquid,  acts  as  a  focus  for  the 
development  of  the  organisms,  which  form  colonies  hanging 
down  into  the  broth  in  the  shape  of  stalactites.  The  vessels 
are  shaken  from  time  to  time,  by  which  means  the  hanging 
colonies  are  thrown  down  into  the  fluid,  and  others  form  in 
their  places.  When  growth  has  gone  on  for  a  month  or  six 
weeks,  the  bacilli  are  killed  by  heating  to  70°  C.  for  one  to 

1  Thirty -first  Annual  Report  of  L.G.B.,  1901-2;  Supplement  con- 
taining Report  of  Medical  Officer,  Appendix  B,  No.  1,  p.  361. 
-  Low,  Trans.  Grant  Coll.  Ned.  Soc.,  Bombay,  1903-4,  p.  3. 


208       SERUMS,    VACCINES,    AND    TOXINS 

three  hours ;  the  fluid  is  tested  by  culture  to  make  certain 
that  it  is  sterile,  after  which  it  is  ready  for  use  as  vaccine. 
The  usual  dose  for  an  adult  man  is  3  c.c.,  for  a  woman  rather 
less  (2  to  2^  c.c.) ;  children  receive  still  smaller  amounts. 
The  vaccine  is  given  by  subcutaneous  injection,  and  its  ad- 
ministration is  followed  by  redness  and  swelling  at  the  seat 
of  inoculation,  with  constitutional  symptoms  in  the  form 
of  rise  of  temperature  and  feeling  of  illness.  The  latter 
pass  oft'  in. about  twenty-four  hours,  but  the  patient  should 
spend  the  first  day  after  the  treatment  at  rest,  not  resuming 
his  ordinary  avocations  till  the  second  day. 

Results  Of  inoculation. — Haffkine  considers  that  pro- 
tection against  plague  is  produced  rapidly — at  the  end  of 
twenty-four  hours.  In  view  of  the  facts  ascertained  by 
Wright  as  to  antityphoid  inoculation,  it  seems  likely  that 
there  may  be  at  first  a  period  of  increased  susceptibility 
to  infection,  and  this  has  been  asserted  by  Calmette.  Ban- 
nermann,  however,  denies  that  this  is  the  case,  and  considers 
that  the  injection  does  not  aggravate  an  attack,  if  made 
during  the  incubation  period.  Of  the  figures  given  by 
Haffkine  as  to  the  results  obtained  with  his  inoculations, 
we  may  quote  those  relating  to  the  village  of  Undhera.1 
Among  64  uninoculated  persons  there  were  27  cases  of 
plague,  and  26  of  these  proved  fatal ;  while  among  71  inocu- 
lated persons — members  of  the  same  families  as  the  former 
and  living  under  exactly  the  same  conditions — there  were  8 
cases,  3  of  which  were  fatal.  The  deaths  among  the  un- 
inoculated thus  exceeded  those  among  the  inoculated  by 
8 9 '65  per  cent. 

Leuman2  records  that  of  1,173  mill-hands,  1,040  were 
inoculated  twice  :  among  these  there  were  22  deaths  (2-11 
per  cent.) ;  of  58  inoculated  once,  8  died  (13'79  per  cent.)  ; 
of  75  not  inoculated,  20  died  (26 -6  per  cent.).  Bannermann 
states  that  in  a  total  of  6,000  cases  the  mortality  among  the 

1  lancet,  1899,  i.  1697. 

2  Quoted  by  Miss  Slaughter,  Johns  Hopkins  Hosp.  Bull.,  Nov., 
1903,  p.  307. 


PLAGUE    PROPHYLACTIC  209 

inoculated  was  43'5  percent.,  while  among  the  uninoculatecl 
it  was  73-7  per  cent. 

Among  7,182  inoculated  municipal  labourers,1  14  cases 
of  plague  occurred  (0'19  per  cent.)  with  13  deaths  (O18 
per  cent.)  ;  whereas  among  418  uninoculated  there  were 
28  cases  (6-7  per  cent.)  and  26  deaths  (642  per  cent.). 

Haffkine  ~  sums  up  the  results  so  far  obtained  in  the 
following  figures: — Inoculated,  186,797:  3,399,  or -1'8  per 
cent.,  attacked  with  plague  ;  814,  or  0 '4  per  cent.,  died. 
Uninoculated,  639,630  :  attacks,  49,433,  or  7 '7  per  cent.  ; 
deaths,  29,733,  or  4'7  per  cent 

The  Indian  Plague  Commission  reported  as  follows  with 
regard  to  this  method  of  prophylaxis  : — 

(1)  Inoculation    sensibly   diminishes    the    incidence  of 
attacks  of  plague.     It  is,  however,  not  an  absolute  protec- 
tion against  the  disease. 

(2)  The  death-rate  is  markedly  diminished  by  its  means, 
not  only  the  incidence  of  the  disease  but  also  the  fatality 
(case-mortality)  being  reduced. 

(3)  The  protection  is  not  conferred,  on  those  inoculated, 
for  the  first  few  days  after  the  injection. 

(4)  The  duration  of  the  immunity  is  uncertain,  but  it 
seems  to  last  for  a  number  of  weeks,  if  not  for  months. 

The  mode  of  action  of  Haff  kine's  prophylactic  is  presum- 
ably the  same  as  that  of  other  vaccines,  viz.  it  depends  for 
its  efficacy  on  the  presence  of  the  actual  bacteria  contained 
in  it.  It  has,  therefore,  generally  been  supposed  that  the 
precipitate  that  forms  in  tubes  of  the  vaccine  which  are 
allowed  to  stand,  consisting  of  the  bodies  of  the  dead 
bacteria,  is  the  effective  part  of  the  preparation.  Klein3 
has  thrown  some  doubt  on  the  inert  nature  of  the  super- 
natant fluid.  Probably  it  contains  some  dissolved  bac- 
terial proteins.  He  finds  that  it  has  a  certain,  though 

1  Ann,  Sept.  Sanitary  Commissioner,  1905. 

2  Ann.  de  I'Inst.  Pasteur,  1906,  iv.  825. 

3  Thirty-first  Ann.  Kept,  of  the  Local  Govt.  Board,  1901-2  ;  Supple- 
ment containing  the  Report  of  the  Medical  Officer,  1903,  pp.  357-94. 

O 


210       SERUMS,    VACCINES,    AND   TOXINS 

small,  protective  influence  011  rats.  Further,  he  finds  that 
the  blood  of  immunized  animals  is  agglutinative  towards 
the  B.  peslis,  but  not  bactericidal. 

The  following  is  the  judgment  set  forth  in  the  Annual 
Report  of  the  Sanitary  Commissioner  with  t/t?  G'overn/nent  of 
India  for  1904  :  "  That  its  value  is  great  is  certain  ;  not  only 
does  it  largely  diminish  the  danger  of  plague  being  con- 
tracted, but,  if  it  fails  to  prevent  the  attack,  the  probability 
of  a  fatal  event  is  reduced  by  one-half"  (p.  107).  In  the 
Report  for  the  following  year  (1905)  it  is  stated  that  the 
use  of  the  prophylactic  has  no  ill  effect  on  health,  and  that 
a  marked  protective  influence  lasts  for  six  or  even  twelve 
months  (p.  122). 

Wurtz  and  Bourges^from  experiments  on  white  mice,  find 
that  the  protective  power  of  the  prophylactic  is  consider- 
able, and  lasts  for  a  moderate  period  of  time  (two  or  three 
months).  Haffkine  considers  that  the  protection  afforded  by 
his  prophylactic  lasts  as  long  as  six  months.  The  general 
opinion  in  India  is  that  it  is  "absolutely  safe  for  three 
months."  Leurnan  found  that  the  protection  gained  by 
those  twice  inoculated  was  10  per  cent,  greater  than  that 
of  the  once-inoculated. 

Pfeiffer  ~  considers  that  the  bacilli  lose  some  of  their 
virulence  by  being  cultivated  in  broth,  and  that  their 
efficacy  as  a  protective  is  thus  diminished.  He  has  ac- 
cordingly prepared  a  vaccine  from  fresh  cultures  of  .#. 
pestis  on  agar.  These  are  emulsified  in  broth  or  salt- 
solution,  and  sterilized  at  65°  C.  The  reaction  produced 
by  injection  of  Pfeiffer's  preparations  is  more  intense  than 
that  seen  after  Haffkine's  prophylactic.  No  statistics  are 
available  for  forming  a  judgment  as  to  the  value  of  this 
vaccine  as  compared  with  Haffkine's. 

Kolle   and    Strong3    suggest    vaccination    with    living 

1  Arch,  de  Med.  Experimental^,  etc.,  1902,  p.  145. 

2  Deut.  med.   Woch.,  March  15,  1906,  p.  413. 

3  Quoted  by  Marx,  "  Diagnostik,  Serumtherapie  und  Prophylaxe," 
p.  81. 


ANTI-PLAGUE    VACCINES  211 

attenuated  bacilli,  and  Strong  has  actually  carried  out  this 
method  at  Manilla  without  any  untoward  occurrences. 

TERNI  AND   BANDI'S   VACCINE 

Terni  and  Bandi  l  prepare  a  special  material,  for  use  as 
a  vaccine  against  plague,  by  injecting  guineapigs  intraperi- 
toneally  with  plague  bacilli  and  collecting  the  inflammatory 
fluid  which  is  secreted  into  the  peritoneal  cavities  of  the 
animals.  This  fluid  is  sterilized  by  heating  for  a  short 
period  of  time,  on  each  of  several  consecutive  days,  to  50°  C., 
and  is  preserved  by  the  addition  of  a  small  proportion 
of  carbolic  acid.  The  inventors  claim  that  by  means  of 
this  vaccine  immunity  may  be  produced  in  eight  to  ten 
hours,  and  that  the  blood  of  persons  so  treated  possesses 
bactericidal  powers. 

Havelburg 3  records  that  this  vaccine  was  used  with 
good  effects  in  Brazil.  Pinto 3  also  records  good  results 
with  anti-plague  vaccinations  (with  this  remedy  1)  :  out  of 
1,803  persons  vaccinated  only  2  contracted  plague,  and  one 
of  these  cases  occurred  immediately  after  the  vaccination. 
He  considers  the  results  of  the  treatment  to  be  brilliant, 
but  it  must  be  remembered  that  the  plague  in  Brazil  was 
apparently  of  a  mild  type.  Kolle  and  Otto4  regard  Terni 
and  Bandi's  vaccine  as  quite  inert. 

LUSTIG  AND   GALEOTTI'S   VACCINE 

The  material  used  for  the  preparation  of  Lustig's  serum 
(p.  216)  may  be  employed  for  the  purpose  of  vaccinating 
against  the  disease.  It  is  prepared  by  growing  the  bacilli 
in  broth  and  then  on  agar.  The  bacteria  are  washed  off 

1  Deut.  med.  Woch.,  1901. 

2  Berlin,  klin.  Woch.,  1901. 

3  Abst.  in  Journ.  of  the  American  Med.  Assoc.,  1902,  i.  681.     The 
nature  of  the  vaccine  used  is  not  stated  in  the  abstract.     We  have 
been  unable  to  obtain  the  original  article  (TidssJcrift  f.  d.  Norske  Laege- 
foren.,  Feb.  1,  1902). 

4  Deut.  med.  Woch.,  July  9,  1903. 


212       SERUMS,    VACCINES,    AND    TOXINS 

and  dissolved  in  a  1-per-cent.  solution  of  caustic  potash, 
and  the  fluid  is  neutralized  with  1-per-cent.  acetic  acid.  A 
precipitate  is  thus  formed,  which  is  highly  toxic,  containing 
as  it  does  the  intracellular  poisons  of  the  bacilli.  It  is 
dried  in  vacua,  and  can  be  readily  preserved  in  this  form. 
For  use  as  a  vaccine,  it  is  dissolved  in  a  weak  solution  (1  or 
2  per  cent.)  of  sodium  carbonate.  The  dose  for  an  adult  is 
0-0133  grm.  of  solid  substance.  Two  grm.  of  the  solid 
dissolved  in  1  litre  of  solution  will  afford  material  for  143 
vaccinations.1  Statistics  as  to  the  use  of  this  vaccine  are 
not  available. 

Tavel,  Krumbein  and  Glucksmann2grew  broth-cultures 
by  Haffkine's  method,  and  precipitated  them  after  a 
month's  growth  by  ammonium  sulphate.  The  precipitate 
was  extracted  with  1-per-cent.  caustic  soda,  and  the  nucleo- 
protein  thrown  down  with  acetic  acid.  The  precipitate  is 
dried  in  vacuo  and  stored  as  a  powder.  When  required 
for  use  the  requisite  dose  is  dissolved  in  1-per-cent.  sodium 
carbonate  solution. 

OTHER   VACCINES 

Klein3  has  produced  immunity  in  animals  by  injection 
of  an  emulsion  of  the  dried  organs  of  an  animal  dead  of 
plague,  an  average  guineapig  yielding  5-7  grm.  of  dried 
powder,  equivalent  to  400-600  doses  for  an  adult  rat.  A 
very  similar  procedure  has  been  devised  by  Wallannah.4 
Besredka 5  advises  the  use  of  bacilli  agglutinated  (sensi- 
tized) with  antiplague  serum,  then  killed  by  heat,  and 
finally  suspended  in  salt-solution.  In  a  later  communica- 
tion6 this  observer  described  the  use  of  normal  horse-serum 
as  sensitizer  instead  of  immune  serum. 

1  Deutsch  and  Feistmantel,  "Impstoffe  und  Sera."    Leipzig,  1903. 

2  Zntwhr.f.  Hyg.,  1902,  xl.  239. 

3  See  JSrU.  Med.  Journ.,  1906,  i   155. 

4  Ann.  de  Vlntt.  Pa»teur,  1905,  xix.  589  ;  also  Lancet,  1907,  i.  222. 

5  Ibid.,  1902,  xvi.  918. 

6  Ibid.,  1905,  xix.  479. 


SERUM    TREATMENT   OF    PLAGUE        213 


YERSIN'S    SERUM, 

Preparation  of  the  serum.— The  original  method  of 

Yersin,  Calmefcte  and  Borel '  for  the  preparation  of  anti- 
plague  serum  was  by  inoculation  of  horses  with  fresh  agar- 
cultures  of  the  bacilli.  It  was  subsequently  found  by 
Roux  and  Wladimiroff  that  as  effective  a  serum  could  be 
obtained  by  injection  of  cultures  killed  by  heating  to  50°  C. 
for  one  hour,  by  which  proceeding  the  danger  attending 
the  use  of  living  organisms  could  be  avoided.  Kolle  3  used 
suspensions  heated  to  65°  C.  for  several  hours.  The  serum  is 
difficult  to  prepare  of  adequate  strength,  and  attempts  at  its 
manufacture  are  at  times  unsuccessful.  Krumbein,  Tavel 
and  Glucksmann 3  took  a  year  and  a  half  in  attaining  a  suffi- 
ciently active  serum.  Six  months  is  the  time  usually  found 
necessary  for  the  preparation  of  the  serum  at  the  Paris 
Institute.  Before  the  serum  is  finally  drawn  off  for  use, 
the  blood  of  the  horse  is  tested  on  mice  to  ascertain  that  no 
living  bacilli  are  contained  in  it.  One-tenth  of  a  cubic 
centimetre  of  scrum  should  protect  a  mouse  from  a  dose  of 
living  bacilli  which  kills  a  control  mouse  in  two  or  three  days. 
Value  Of  Yersin's  serum. — Yersin  gives  the  follow- 
ing account  of  his  experiences  in  Amoy.4  Twenty-three 
cases  were  treated  in  all.  Of  these — 

Six  cases  treated  on  the  first  day  ;  all  recovered  within 

24  hours.   Dose,  20-30  c.c.    No  suppuration  occurred. 
Six  cases  treated  on  the  second  day  ;  all  recovered  within 

3-4  days.     Dose,  30-50  c.c.     No  suppuration. 
Four  cases  treated  on  the  third  day ;  all  recovered  within 

4-5  days.     Dose,  40-60  c.c.     Two  suppurated. 
Three  cases  treated  on  the  fourth  day  ;   all  recovered 

within  5-6  days.    Dose,  20-50  c.c.    One  suppurated. 

1  Ann.  de  I'Jnst.  Pasteur,  1895,  ix.  590. 

2  Deut.  med.  Woeh.,  1897. 

3  Centralbl.f.Bakt.,  1901,  xxx.  742. 

4  Ann.  de  Vlnst.  Pasteur,  1897,  xi.  81. 


214       SERUMS,    VACCINES,    AND    TOXINS 

Four  cases  treated  on  the  fifth  day,  two  died.     Dose, 
60-90  c.c. 

In  Nhatrang  (Annam),1  out  of  33  cases  treated  with  the 
serum,  19  recovered  and  14  died  (mortality,  42  per  cent.); 
of  39  cases  not  treated,  all  died  (100  per  cent.). 

Calmette  and  Salimbeni 2  used  the  serum  in  Oporto. 
They  report  that,  of  142  cases  injected  with  the  serum,  24 
died,  a  mortality  of  14 '78  per  cent. ;  among  72  patients  not 
so  treated,  46  died,  a  death-rate  of  63-72  per  cent.  They  find 
that  the  serum  reduces  the  pain  in  the  bubo  and  limits  the 
inflammation  ;  suppuration  is  often  aborted  by  its  early  use. 

Cairns,3  as  the  result  of  experience  of  the  remedy  in 
cases  at  Glasgow,  concludes  that — 

(1)  Yersin's  serum  is  a  remedy  of  the  greatest  value. 

(2)  Its  action  is  bactericidal — as  shown  by  the  degenera 
tion  induced  in  the  bacilli — as  well  as  antitoxic. 

(3)  Good  results  are  best  secured  by  the  early  administra- 
tion of  large  doses,  snbcutaneously,  into  the  area  from  which 
lymph  drains  towards  the  bubo,  and  also  intravenously. 

(4)  In  mild  cases  the  subcutaneous   method   alone  is 
sufficient,  but  in  severe  attacks  combined  subcutaneous  and 
intravenous  administration  is  advisable.      The  total  com- 
bined dose  in  the  latter  condition  should  be  150  to  300  c.c., 
the  proportion  given  intravenously  varying  with  the  severity 
of  the  attack. 

Valassopoulo  4  used  the  serum  supplied  by  the  Pasteur 
Institute  (Paris)  in  100  cases  ;  among  64  treated  during 
the  first  three  days  of  the  disease  the  mortality  was  10  per 
cent. ;  among  36  treated  on  the  fourth  day  and  later  it  was 
47  per  cent.  The  mortality  among  42  cases  not  treated 
with  serum  was  35  per  cent.,  but  in  this  class  were  included 
many  very  mild  attacks.  Valassopoulo  agrees  with  Roux 

1  Ann.  de  I'Inst.  Pasftur,  1899,  xiii.  251. 

2  Ibid.,  1899,  xiii.  865. 

3  Lancet,  1903,  i.  1287. 

4  Suit.  Soc.  Med.  des  Hop.,  1908,  p.  541. 


SERUM  TREATMENT  OF  PLAGUE    215 

that  the  serum  is  antitoxic,  not  bactericidal.  Finally, 
the  Indian  Plague  Commission1  concluded  that  neither 
Yersin's  nor  Rowland's  serum  was  effectual  in  septicremic 
cases,  and  that  in  bubonic  cases  their  value  was  doubtful. 

Dose  and  administration  of  the  serum.  —  From 
what  has  just  been  said  it  may  be  seen  that  large  doses  of 
the  serum  are  to  be  employed,  if  the  amount  is  available. 
Yersin  appears  to  give  doses  of  20  to  90  c.c.  according  to 
the  date  at  which  the  case  comes  under  treatment.  He 
administers  the  remedy  subcutaneously.  Cairns  used  still 
larger  amounts  (150  to  300  c.c.),  and  gave  the  serum  both 
subcutaneously  and  intravenously ;  and  the  advantages 
of  employing  large  doses  are  also  enforced  by  Duprat.2 
Brownlee 3  insists  on  the  intravenous  use  of  the  serum, 
and  advises  doses  of  60  c.c.  ;  Lignieres  4  gives  the  same 
advice.  There  is  no  reason  to  fear  the  use  of  the  larger 
amounts.  The  only  ill  effects  recorded  have  been  pains  in 
the  joints  and  erythema,  noted  by  Calmette  and  Salimbeni, 
analogous  to  those  associated  with  diphtherial  and  other 
antitoxins. 

Choksy 5  advises  an  initial  injection  of  100  c.c.,  followed 
by  two  others  of  the  same  amount  at  intervals  of  six  to 
eight  hours.  These  may  be  supplemented  by  subsequent 
injections  of  smaller  quantities. 

Denys  and  Tartakovsky 6  insist  on  the  importance  of 
local  injections  of  the  serum  into  the  neighbourhood  of  the 
buboes.  Thus,  in  cases  of  inguinal  buboes,  the  remedy 
should  be  injected  into  the  leg.  They  found  that  if  guinea- 
pigs  were  inoculated  intraperitoneally  with  plague  bacilli, 
O'l  c.c.  of  serum  injected  into  the  peritoneal  cavity  would 
act  as  a  protective  dose;  whereas  10  c.c.  administered 

1  Journ.  of  Hygiene,  1912,  xii.  Suppl.  II.,  326. 

2  Ann.  de  rinst.  Pasteur,  1903,  xvii.  599. 

3  Lancet,  1901,  ii.  435. 

4  Ann.  de  VInst.  Pasteur,  1901,  xv.  808. 

5  Sept.  on  Treatment  of  Plague,  Bombay,  1906. 

6  Semaine  Med.,  1900,  p.  40, 


216       SERUMS,    VACCINES,    AND    TOXINS 

subcutaneously  was  of  no  avail  in  saving  the  lives  of  the 
animals. 

Prophylactic  use  of  the  serum. — Yersin  records 

that  in  Nhatrang  no  cases  of  plague  occurred  among  those 
who  had  received  prophylactic  injections  of  the  serum. 
Calmette  and  Salimbeni  also  used  the  serum  as  a  protective, 
giving  doses  of  5  c.c.  injected  under  the  skin  of  the  abdomen. 
According  to  these  observers  the  protection  only  lasts 
fifteen  days,  so  that  it  is  advisable  to  repeat  the  injections 
at  the  end  of  this  time.  Calmette  recommends  the  injec- 
tion of  some  of  the  serum  along  with  the  use  of  Haffkine's 
prophylactic,  in  order  to  counteract  the  first  depressing 
effects  of  the  latter.  This  suggestion  seems  worthy  of 
serious  consideration  when  the  prophylactic  is  used  in  the 
actual  presence  of  an  epidemic.  Serum-rashes,  joint-pains, 
and  hyperidrosis  may  follow  the  use  of  this  serum. 

LUSTIG'S    SERUM 

Antitoxic  serum. — Yersin's  serum  appears  to  be  bac- 
tericidal in  nature,  though  it  may  possess  some  antitoxic 
power.  Lustig  considers  that  the  curative  serum  for  plague 
should  be  mainly  antitoxic,  and  he  therefore  proceeds  to 
obtain  such  a  preparation  by  immunizing  horses  with  the 
vaccine  material  already  described  (p.  211),  which  consists 
of  a  poisonous  bacterio-protein.  The  immunizing  process 
lasts  two  or  three  weeks. 

Lustig  and  Galeotti1  record  that  among  475  cases  of 
plague  treated  with  the  serum  the  recovery-rate  was  39-36 
per  cent.,  whereas  among  5,952  patients  not  so  treated  the 
recoveries  were  only  20-6  per  cent.  Choksy  ~  puts  the  rate 
of  recovery  after  use  of  the  serum  at  38'2  per  cent.,  while 
in  other  patients  not  so  treated  it  was  only  19-5  per  cent. 
In  another  series  of  cases,  480  patients  were  treated  with 
the  serum,  and  the  same  number  without  it.  Eliminating 
various  sources  of  error,  he  found  that  the  recoveries  among 

1  Brit.  Med.  Journ.,  1901,  i.  206. 
Lancet,  1900,  ii.  291. 


SERUM  TREATMENT  OF  PLAGUE    217 


the  serum  cases  amounted  to  3 9 '6 2  per  cent.,  whereas 
among  the  non-injected  cases  they  were  only  20-21  per 
cent.  The  following  table  shows  the  results  obtained  in 
India  with  this  remedy  (Choksy) l : — 

TABLE  SHOWING  KESULTS   OF   TREATMENT  OF  PLAGUE  WITH  LUSTIG'S 
SERUM.     BOMBAY,  1898-1901 


Differ 

Period 

Serum-treated 
patients 

Patients  under 
ordinary  treatment 

ence  in 
favour 
of  the 
serum- 
patients 
percent. 

May  to  Oct.,  1898... 

No. 

Deaths 

Case- 
mortali- 
ty, per 
cent. 

No. 

Deaths 

Case- 
mortali- 
ty, per 
cent. 

22-7 

257 

145 

56-4 

752 

595 

79-1 

Jan.   to   April    and 
June,  1899  

189 

124 

65-60 

884 

734 

83-03 

17-4 

May,  1899,  and  July, 
1899,toAug.,1900 

484 

329 

68-00 

484 

385 

79-5 

11-5 

Aug.,  1900,  to  Feb., 
1901      (3      extra 
cases)  

55 

36 

65-45 

184 

144 

78-26 

12-81 

March,     April,   and 
May,  1901  

104 

81 

77-82 

102 

81 

79-42 

1-53 

Mayr  3  gives  an  account  of  361  cases  treated  with  the 
serum,  the  recovery-rate  being  33 -8  per  cent. ;  while 
among  patients  treated  by  other  methods  only  21-3  per 
cent,  survived.  He  says  that  the  general  recovery- rate  in 
hospitals  where  the  serum  was  used  was  4-5  per  cent, 
higher  than  in  ,  those  where  it  was  not  employed.  He 
considers  that  the  curative  properties  of  the  serum  are 
definitely  established. 

1  "  The  Treatment  of  Plague  with  Professor  Lustig's  Serum," 
p,  110.     Bombay,  1903, 

2  Lancet,  1900,  ii.  461. 


218       SERUMS,    VACCINES,    AND    TOXINS 

A  mere  study  of  the  above  records  does  not  produce  a 
very  favourable  impression  of  the  value  of  the  remedy. 
The  results  obtained  do  not  seem  so  striking  as  those  seen 
with  Yersin's  preparation.  More  experience  is,  however, 
needed  to  enable  us  to  form  a  judgment.  The  opinions  of 
those  who  have  used  Lustig's  serum,  as  quoted  above 
appear  to  be  favourable,  and  Choksy,1  in  his  most  recent 
statistics,  states  that  the  use  of  Lustig's  serum  reduces  the 
mortality  from  74-5  per  cent,  to  10-5  per  cent.  He  gives 
an  initial  dose  of  100  c.c.  followed  by  siinilar  amounts  at 
twelve  and  twenty-four  hours. 

Rowlands  and  MacConkey's  serum. — Rowlands2 

prepared  a  vaccine  by  mixing  the  growth  from  the  sur- 
face of  agar  with  a  suitable  quantity  of  anhydrous  sodium 
sulphate.  This  was  used  by  MacConkey3  in  immunizing 
horses,  but  the  serum  of  these  animals  did  not  reach  a  very 
high  antitoxic  value  (see  p.  215). 

CONCLUSIONS 

1.  Hajfkine's  prophylactic  is  a  valuable  means  of  pro- 
tection against  plague.     There  is  some  doubt  as  to  whether 
its  use  in  the  presence  of  an  epidemic  is  advisable,  owing  to 
the  possibility  of  an  increased  susceptibility  being  at  first 
produced.     The  employment  of   some   of   Yersin's   serum 
along  with  the  vaccine  seems  to  offer  a  means  of  counter- 
acting this  depressing  effect,  if  it  really  exist. 

2.  Sufficient  evidence  is  not  yet  available  to  enable  us  to 
decide  as  to  the  efficacy  of  Lustig's  or  of  Terni  and  Bandi's 
vaccine. 

3.  Yersin's  serum  is  of  value  as  a  remedy  for  the  disease. 
It  should  be  given  early  in  the  case  and  in  large  quantities. 
Some  of  the  serum  should  be  injected  intravenously,  the 
rest  subcutaneously  into  the  area  of  skin  which  is  drained 

1  Zeitschr.f.  Immunitdttforsch.,  1912,  p.  1074. 

2  Journ.  of  Hygiene,  1910,  x.  536. 

3  Ibid.,  Plague  Suppl.  II.  1912,  p.  387. 


PLAGUE  219 

by  the  lymphatics  leading  to  the  bubo.     The  dose  may  be 
from  60  to  150  or  even  300  c.c. 

4.  Yersin's  serum  may  also  be  used  prophylactically 
(dose  5  to  lOc.c.),  but  the  protection  gained  is  transitory, 
so  that  repeated  injections  are  necessary  in  presence  of  an 
epidemic  of  plague. 

5.  The  claims  of  Lustig's  serum  as  a  remedy  are  less 
well   established   than  those  of  Yersin's  serum,  but  some 
evidence  has  been  adduced  in  its  favour. 


CHAPTER   XII 
CHOLERA 

Causal  organism. — The  organism  which  is  responsible 
for  the  production  of  cholera  is  a  curved,  rod-shaped  bac- 
terium, which  was  discovered  by  Koch,  and  is  called  the 
Vibrio  cholerce,  or  Spirillum  cholera;. 

Toxins. — It  has  not  been  possible  to  prepare  any 
potent  solutions  of  the  toxins  of  the  organisms  in  artificial 
media  :  the  toxins  are  therefore  classed  as  "  intracellu- 
lar."  Ransom,1  however,  obtained  from  cultures  a  solid 
substance  which  induced  the  formation  of  an  antitoxin 
when  injected  into  goats.  Metchnikoff  and  his  assistants 
also  succeeded  in  obtaining  a  feebly  toxic  fluid  by  growing 
the  vibrios  in  peptone-water.  These  preparations  can, 
however,  only  faintly  reproduce  the  toxins  which  are 
manufactured  in  some  forms  of  the  disease,  of  which  the 
virulence  is  such  that,  in  acute  cases,  death  may  occur 
within  a  few  hours.  The  bodies  of  the  vibrios  contain 
within  them  a  substance  which  produces  necrosis  of  tissue 
when  they  are  injected  subcutaneously. 

Macfadyen2  obtained  an  antitoxic  serum  by  injecting 
rabbits  and  goats  with  ground-up  cultures  of  the  vibrios  ;  it 
was  also  agglutinative  and  bacteriolytic.  The  endotoxin 
of  the  bacteria  is  thermolabile,  being  destroyed  at  a 
temperature  of  55°  to  60°  C. 

Allusion  has  already  been  made  to  Pfeiffer's  experi- 
ments (p.  9)  on  the  destruction  of  cholera  vibrios  in  the 

1  Deut.  med.  Woeh.,  1895. 

2  Lancet,   1906,  ii.   494.      Cf.  Brau  and  Denier,  Ann.  dc   VInst. 
Pasteur,  1906,  xx.  578  ;   Hahn,  Munch,  med.  Woch.,  1906,  No.  23. 

220 


PATHOLOGY   OF    CHOLERA  221 

peritoneal  cavity  of  immune  animals.  It  is  found,  however, 
that  if  a  large  dose  of  the  bacteria  is  injected  into  an 
"  immune "  guineapig,  the  animal  dies  in  spite  of  the 
destruction  of  the  organisms ;  in  other  words,  although 
the  bacteria  are  broken  up  and  killed  by  the  serum,  this 
has  no  power  of  neutralizing  their  intracellular  toxins, 
which  are  set  free  and  kill  the  gnineapig. 

These  experiments  on  animals  are  of  considerable 
importance  from  the  point  of  view  of  human  therapeutics. 
They  show  that  there  can  be  little  hope  of  treating  the 
disease,  when  already  developed,  by  means  of  a  bactericidal 
serum  ;  for  if  the  bodies  of  the  bacteria  are  so  toxic  in 
themselves,  such  a  serum,  by  leading  to  rapid  breaking-up  of 
those  vibrios  which  were  already  present,  could  but  produce 
speedier  intoxication.  The  hope  of  preparing  an  antitoxic 
serum  is  at  present  slight,  as  attempts  to  produce  a  potent 
toxin  in  artificial  media  have  failed,  and  it  is  only  by 
means  of  a  toxin  of  high  potency  that  an  effective  antitoxic 
serum  can  ba  obtained.  Hence  it  is  in  the  direction  of 
prophylaxis — of  inducing  a  condition  of  active  immunity 
which  shall  destroy  the  bacteria  that  first  gain  access  to 
the  body,  before  they  have  increased  in  numbers  up  to  a 
dangerous  degree — that  the  best  hope  of  combating  the 
disease  seems  to  lie. 

DIAGNOSIS 

Agglutination. — The  cholera  vibrios  are  agglutinated 
by  means  of  the  serum  of  convalescents  from  the  disease, 
and  by  that  of  animals  artificially  immunized.  Karwacki l 
states  that  agglutination  of  the  vibrios  with  the  serum  of  a 
suspected  case  in  a  dilution  of  1  :  30  is  a  satisfactory  proof 
of  cholera.  The  reaction  is  of  no  use  for  the  diagnosis  of 
cholera,  as  it  does  not  occur  till  late  in  the  disease  ;  it  may, 
however,  be  employed  for  the  identification  of  a  particular 
vibrio  as  that  of  cholera  Asiatica,  since  there  are  several 
organisms  which  belong  to  the  same  group  and  closely 
1  Zeitschr.f.  Hyg.,  1906,  p.  39. 


222       SERUMS,    VACCINES,    AND   TOXINS 

resemble  one  another.  A  more  certain  test  is  afforded  by 
Pfeiffer's  experiment  :  the  organisms  in  question  are  in- 
jected into  the  peritoneal  cavity  of  a  guineapig  along 
with  a  sufficient  quantity  of  a  serum  known  to  be  bacteri- 
cidal towards  the  V.  cholerce,  and  their  fate  is  investigated. 
A  serum  of  the  above  nature  may  be  readily  produced  by 
injecting  a  rabbit  subcutaneously  with  laboratory  cultures 
of  the  cholera  organisms,  and  may  be  preserved  by  means 
of  0'5  per  cent,  carbolic-acid  solution. 

"  Immune  "  serum  is  capable  of  dissolving  V.  cholera 
in  a  test-tube,  when  it  is  fresh,  but  it  rapidly  loses  the 
power ;  this,  however,  may  be  regained  by  the  addition  of  a 
little  fresh  normal  serum  of  the  same  species  of  animal. 
In  other  words,  the  complement  or  alexine  tends  to  dis- 
appear in  course  of  time,  whereas  the  copula  or  immune 
body  remains  stable. 

Complement-fixation. — Arnako  and  Kozima1  have 
found  a  positive  complement-fixation  reaction,  using  as 
antigen  either  the  fluid  of  typical  rice-water  stools  or  a 
culture  of  the  vibrios  in  peptone-water. 

VACCINATION  AGAINST  CHOLERA 
Experimental  vaccination  against  cholera  was  first 
carried  out  by  Ferran,  who  employed  broth-cultures  of  the 
Vibrio  cholerce  derived  from  the  stools  of  patients.  No 
definite  statistics  are  available  as  to  the  amount  of  success 
which  Ferran  obtained  by  his  inoculations.  The  methods 
in  use  at  the  present  time  for  anticholera  vaccination  are 
that  of  Haffkine  and  that  of  Kolle. 

Haffkine's  cholera  vaccine. — This  method  involves 

the  use  of  two  vaccines,  a  weaker  and  a  stronger,  designated 
respectively  I.  and  II.,  the  former  being  administered  first 
in  order  to  avoid  the  destructive  effect  of  the  virulent 
organisms  on  the  tissues  at  the  point  of  injection.  Neither 
of  these  vaccines  is  artificially  devitalized.  The  weaker 
vaccine  is  obtained  by  growing  the  bacteria  on  agar  at  a 
1  Zeitschr.f.  Chemoiherap.,  1912,  Orig.,  Bd.  i.,  Heft  1. 


CHOLERA   VACCINES  223 

temperature  of  39°  C.  in  a  current  of  air.  The  stronger 
vaccine  is  prepared  by  passing  the  vibrios  through  a  series  of 
guineapigs  till  a  virus  is  obtained  which  is  invariably  fatal 
to  these  animals  within  eight  hours.  The  method  adopted 
is  as  follows  :  A  guineapig  is  inoculated  intraperitoneally 
with  a  laboratory  culture  of  the  organisms,  which  usually 
causes  death  within  twenty-four  hours.  The  peritoneal 
exudate  is  collected  from  the  dead  guineapig,  and  is 
incubated  for  ten  hours  at  35°  C.,  the  optimum  temperature 
for  the  organisms.  (This  is  done  in  order  to  give  the 
bacteria  time  to  multiply,  as  they  are  only  found  in  com- 
paratively small  numbers  in  the  first  peritoneal  fluid.) 
After  incubation  the  fluid  from  the  first  guineapig  is 
injected  into  the  peritoneum  of  a  second,  and  so  on  through 
a  series  of  animals,  till  the  "  virus  fixe  "  is  obtained.  This 
is  cultivated  for  twenty-four  hours  on  agar-tubes,  the  whole 
surface  of  a  sloped  agar-tube  being  inoculated.  When 
growth  has  occurred,  the  whole  culture  is  washed  off  with 
sterile  broth,  and  the  quantity  made  up  to  8  c.c.  One 
cubic  centimetre  (one-eighth  part)  of  this  constitutes  a 
dose  of  the  vaccine.  The  virulent  cultures  soon  become 
attenuated  by  growth  on  laboratory  media,  and  must  be 
again  raised  in  virulence  by  passage  through  animals. 

The  injection  is  given  hypodermically  in  the  flank,  and 
an  interval  of  five  days  should  separate  the  two  vaccinations. 
The  procedure  is  followed  by  redness,  swelling,  and  pain  in 
the  side,  and  by  a  febrile  reaction.  The  degree  of  protection 
afforded  is  said  to  be  proportional  to  the  severity  of  the 
symptoms.  The  immunity  conferred  by  each  injection  is 
attained  in  five  days  ;  hence  the  selection  of  this  interval 
of  time  between  the  injections.  Before  employing  the 
vaccines  generally,  Haffkine  made  trial  of  them  on  him- 
self and  others  :  no  ill  effects  were  produced.  He  has 
now  given  70,000  injections  in  42,179  individuals  with- 
out accident. 

Kolle's  vaccine. — This  is  an  emulsion  of  the  killed 
bacteria,  and  is  derived  from  agar-cultures  of  a  virulent 


224       SERUMS,    VACCINES,    AND    TOXINS 

strain  of  the  cholera  virus  sterilized  at  a  temperature 
of  58°  C.,  standardized  to  contain  4  mg.  of  the  culture 
in  1  c.c.,  and  preserved  with  0'5  per  cent,  phenol.  A  first 
injection  of  0'5  c.c.  of  the  vaccine  is  followed  eight  days 
later  by  a  second  of  1  c.c. 

The  injection  is  followed  by  local  redness  and  swelling, 
and  a  rise  of  temperature  often  occurs,  which,  however, 
passes  off  within  forty-eight  hours. 

Results  Of  vaccination. — Haffkine  *  gives  the  follow- 
ing figures  relating  to  his  experiences  at  Calcutta  and 
Lucknow  : — 


POPULATION 

CASES 

DEATHS 

Non-inoculatec 
Inoculated 

1735     ... 
...     500     ... 

Total      Percentage 
174          10-63 
21           4-20 

Total    Percentage 
113          651 
19          3-80 

Powell 2  also  reports  favourably  on  the  results  ob- 
tained with  this  prophylactic,  and  gives  the  following 
statistics  : — 


POPULATION 

CASES 

DEATHS 

Total 

Percentage 

Total 

Percentage 

Fatality 

Non-inoculated   6,549 

198 

3-02 

124 

1-89 

63% 

Inoculated      ..  5,778 

27 

0-48 

14 

0-24 

50% 

Out  of  275  uninoculated  coolies  on  steamers  plying 
between  Goalundo  and  Dilrugarh,  8 '36  per  cent,  contracted 
cholera,  and  10  died;  while  of  414  who  had  been 
inoculated,  only  1-2  per  cent,  contracted  the  disease,  and 
none  died  of  it.3 

In  1903  the  figures  were  as  follows: — 2,633  non-inocu- 

1  Brit.Med.  Journ.,  1895,  i.  219. 
-  Journ.  of  Trap.  Med,  1899,  No.  2. 

3  Ann.   Rept.  of  the  Sanit.   Commissioner  with  the  Goi't.  of  India, 
1901,  p.  88. 


CHOLERA   VACCINATION 


225 


lated,  68  cases,  16  deaths;  199  inoculated,  4  cases,  1  death. 
In  1904,  614  non-inoculated,  6  cases,  3  deaths;  75  inocu- 
lated, no  case.  The  inoculations  have,  nevertheless,  been 
discontinued  by  the  wisdom  of  the  Government.1 

Savas 2  reports  on  the  excellent  results  obtained  in  a 
large  body  of  troops  (114,803),  and  his  figures  may  be 
summarized  thus  : — 


POPULATION 

CASES 

DEATHS 

Xon-inoculated  ...  8,968  ... 
Inoculated  once  ...14,613  ... 
Inoculated  twice...  91,224  ... 

Total      Percentage 
831           9-0 
618            4-0 
644           0-7 

Total     Percentage 
166            27 
74            12 
(55            10 

Cardamatis  3  gives  the  following  figures  with  regard  to 
an  epidemic  of  cholera  in  the  island  of  Chalcidice  : — 


POPULATION 

CASES 

DEATHS 

Before  inoculation  was 

Total      Percentage 

Total     Percentage 

introduced...          ...   11,256 

300           2-10 

170          56-66 

After  one  inoculation  14,086 

38           0-26 

15         39-47 

After  two  inoculations  14,071 

2           0-01 

0           0 

Part  of  the  above  reductions  in  incidence  and  mortality 
may  have  been  due  to  measures  of  isolation  and  disinfec- 
tion, and  possibly  part  to  diminution  in  the  virulence  of 
the  epidemic,  but  the  figures  are  striking.  Cardamatis 
emphasizes  the  fact  that  inoculation,  even  with  two  doses 
of  vaccine,  is  not  an  absolute  preventive  of  the  disease. 
He  also  records  as  a  by-effect  of  the  procedure  menstrual 
disturbances  in  women — either  retardation  of  the  onset  of 
the  period  or  cessation  of  the  flow — if  vaccination  was 

1  Ann.  Rept.  of  the  Sanit.   Commissioner  with  the  Govt.  of  India, 
1903  and  1904. 

2  Wien.  kiln.  Woch.,  1914,  p.  1094. 

3  Bull.  Soc.  Path.  Exot.,  1914,  vii,  447. 


226       SERUMS,    VACCINES,    AND    TOXINS 

performed  during  its  activity ;  or  the  incidence  of  uterine 
pain.  Menorrhagia  was  seldom  produced. 

It  appears  from  these  figures  that  the  use  of  Haffkine's 
prophylactic  inoculations  confers  a  certain  measure  of  im- 
munity to  cholera.  Larger  statistical  material  is  necessary 
to  enable  us  to  gauge  with  accuracy  the  exact  amount  of 
protection  which  it  affords. 

There  is  reason  to  believe  that  this,  like  other  methods 
of  vaccination  with  pathogenic  bacteria,  may  produce 
an  initial  fall  in  the  resistance  of  the  individual  to  the 
disease ;  and  therefore  it  may  be  questioned  whether  it 
would  be  wise  to  undergo  inoculation  in  the  presence 
of  an  epidemic.  Complete  immunity — so  far  as  it  is  ever 
complete — is  gained  at  the  end  of  ten  days,  in  which 
time  two  vaccinations  have  been  carried  out.  Those  who 
are  about  to  visit  an  infected  area,  but  who  can  allow  this 
period  of  time  to  elapse  before  they  are  actually  brought 
face  to  face  with  the  epidemic,  would  be  wise  to  undergo 
vaccination.  It  is  possible  that  a  certain  measure  of  protec- 
tion may  be  gained  by  the  end  of  the  fifth  day,  as  a  result 
of  the  first  inoculation  ;  but  this  is  probably  slight.  It  is 
noteworthy  that  the  prophylactic  diminishes  the  liability 
of  the  inoculated  person  to  contract  cholera,  rather  than  the 
fatality  of  the  disease  when  it  occurs  in  those  who  have 
been  vaccinated. 

Marx  points  out  that  an  element  of  doubt  exists  in  the 
statistics  of  cholera  vaccination,  in  that  it  is  the  better- 
informed  upper  classes  who  submit  to  inoculation,  while  the 
poorer  portion  of  the  population,  owing  to  ignorance  and 
superstition,  refuse  to  avail  themselves  of  the  protection 
offered.  It  is  among  the  latter  that  the  incidence  of  the 
disease  may  be  expected  to  be  greatest  and  the  mortality 
highest,  so  that  the  apparent  protection  afforded  to  the 
vaccinated  may  really  be  due  to  their  better  circumstances 
in  other  respects. 

Fear  has  been  expressed  that  the  necrosing  action  of 
the  bacilli  may  act  injuriously  when  they  are  used  as  a 


CHOLERA  VACCINATION  227 

vaccine.  Kolle,1  however,  believes  that  this  danger  may 
be  neglected  in  practice,  and  that  no  ill  effects  may 
be  expected  from  an  injection  of  virulent  organisms 
without  preparatory  inoculation  with  attenuated  cultures. 
He  therefore  at  first  advised  only  one  vaccination,  with  the 
virulent  organisms,  thus  producing  more  rapid  immunization. 
Powell  records  that  Haffkine  now  uses  more  virulent  cultures 
for  his  first  vaccination,  and  that  no  suppuration  or  other 
accident  has  been  noted  as  a  result  of  this  procedure. 

Strong  3  devised  a  mode  of  vaccination  against  cholera 
by  means  of  the  body-substance  of  the  vibrios,  which  he 
calls  "cholera  receptors."  The  vaccine  is  obtained  by 
"  autolytic  digestion  "  of  the  organisms,  i.e.  by  incubating 
an  emulsion  of  them  in  sterile  water,  in  which  they  break 
up  spontaneously.  The  following  are  the  directions  given 
by  the  writer  : — 

"  The  surface  of  flat-sided  flasks  filled  with  cholera  agar  (sic)  are 
sprayed  with  20-hour  bouillon  cultures,  and  the  flasks  then  put  aside  in 
the  incubator  at  37°  C.  for  20  hours  ;  the  growth  is  then  emulsified  with 
sterile  water,  removed  from  the  surface  of  the  agar,  and  the  emulsion 
placed  in  a  sterile  flask  and  kept  at  a  temperature  of  60°  C.  for  24 
hours.  The  mixture  is  then  put  aside  in  the  incubator  for  from  2  to 
5  days.  The  best  results  were  obtained  apparently  after  5  days' 
autolytic  digestion.  After  such  digestion  the  emulsion  is  filtered 
through  a  Reichel  filter.  The  fluid  thus  obtained  must,  of  course,  be 
examined  for  sterility  and  carefully  standardized  before  being  used  as 
a  human  vaccine." 

No  trial  of  the  method  on  man  has  apparently  been 
made.  Strong  considers  that  the  disagreeable  effects 
inseparable  from  the  use  of  Haffkine's  vaccine  render  it 
unsuitable  for  general  use. 

Murata,3  who  inoculated  with  dead  organisms,  giv^es  the 
following  figures': — 

Inoculated/    10,000,   with  6    attacks   and  42  per  cent. 

1  Zeitschr.  f.  Hygiene,  18P4,  Bd.  xvi.  and  xviii. ;  and  Centratll.  /. 
Jiakteriot.,1.  1896,  xix.  97,  127. 

2  Amer.  Med.,  Aug.  15,  1903,  p.  272. 

3  Centralbl.f.  £akteriol.,I.  Orig.,  1904,  xxxv.  605. 


228       SERUMS,    VACCINES,    AND   TOXINS 

fatality;  uninoculated,  10,000,  13  attacks  and  To  percent, 
fatality. 

PASSIVE   IMMUNITY  TO    CHOLERA 

The  protection  conferred  by  Haffkine's  prophylactic  is 
of  the  nature  of  active  immunity,  the  blood  of  the 
patient  gaining  bactericidal  power,  and  thus  destroying  those 
organisms  which  first  enter  the  body  and  tend  to  cause 
infection.  It  has  already  been  mentioned  that  the  prospects 
of  obtaining  a  bactericidal  or  antitoxic  serum  as  a  cure  for 
the  disease  are  not  hopeful.  Popoff1  vaccinated  a  cow 
with  cholera  vibrios,  and  found  that  the  milk  contained  a 
protective  substance  which  conferred  some  degree  of  im- 
munity on  guineapigs.  This  substance  was  destroyed  by 
boiling  the  milk. 

A  serum  prepared  by  Schurupow  has  been  used  in 
Russia  in  cases  occurring  in  children,  100-180  c.c.  of 
serum  being  given,  along  with  100  c.c.  of  warm  saline 
solution  for  each  year  of  the  child's  life.  The  serum 
must  be  given  early,  within  twelve  hours  of  the  onset 
of  the  disease.2 

CONCLUSIONS 

1.  Prophylactic  inoculation   with  Haffkine's  or  Kolle's 
vaccine   confers   a    certain    measure  of   protection  against 
cholera,  and   should  be  employed  by  those  who  are  called 
upon  to  reside  in  districts  in  which  they  will   be  exposed 
to  infection.     It  should  probably  not  be  performed  in  the 
actual   presence   of   an    epidemic,    owing   to  the  increased 
susceptibility  induced    during  the  first  few  days  after  the 
injection. 

2.  At  present  no  therapeutic  serum  has  been  adequately 
proved  to  possess  curative  properties,  and  in  the  treatment 
of  the  disease  Rogers's  saline  infusions  should  be  employed 
along  with  other  therapeutic  measures. 

1  Rousxki  Vra'ch,  1893,  No.  10. 
a  Kiibanskaja  i'nft.,  1910,  p.  8. 


CHAPTER   XIII 
ENTERIC    FEVER 

Causal  organism. — -The  Bacillus  typhosus  was  discovered 
by  Eberth  in  1881,  and  is  consequently  often  called  Eberth's 
bacillus.  It  is  found  in  considerable  quantities  in  the 
alimentary  canal  of  infected  persons,  but  also  exists  in 
large  numbers  during  the  first  week  or  so  of  the  disease 
in  the  blood  of  the  infected  individual ;  later  it  is  found  in 
the  spleen,  in  the  lymphatic  glands  of  the  abdomen,  and 
in  the  gall-bladder,  where  it  sometimes  forms  the  nucleus 
of  a  gall-stone.  The  organisms  are  excreted  to  a  certain 
extent  in  the  urine,  as  well  as  in  the  faeces,  and  appear 
in  the  sputum  of  cases  complicated  by  lesions  of  the  lungs 
or  larynx.  It  appears,  therefore,  that  the  disease  cannot 
be  considered  a  local  infection  only,  but  is  of  the  nature 
of  a  septicaemia  or  general  infection  (Wright). 

Complications. — As  in  other  infective  diseases,  the 
complications  met  with  in  the  course  of  enteric  fever,  or 
during  convalescence  from  it,  are  largely  due  to  secondary 
invasion  by  other  organisms  which  effect  a  lodgment  in 
tissues  worn  out  by  conflict  with  a  primary  illness.  The 
hectic  temperature  met  with  in  the  fourth  week  in  severe 
cases  of  enteric  fever  is  probably  due  to  the  action  of 
pyogenic  bacteria ;  while  to  these,  or,  in  some  instances, 
to  the  Bacillus  coli,  are  usually  to  be  ascribed  most  of  the 
suppurative  lesions  (periostitis,  perichondritis,  otitis,  epi- 
didymitis,  etc.)  which  are  seen  in  the  later  weeks.  Venous 
thrombosis,  so  often  met  with  in  convalescence,  is  also  to 
be  attributed  to  pyogenic  bacteria.  In  some  cases,  how- 
ever, typhoid  bacilli  are  found  in  local  suppurative  lesions, 

229 


230       SERUMS,    VACCINES,    AND   TOXINS 

but  although  they  are  occasionally  the  primary  cause,  they 
are  usually  implanted  in  the  favourable  soil  of  lesions 
caused  by  other  bacteria.  Possibly  the  B.  typhosuti,  when 
its  virulence  is  somewhat  reduced,  becomes  a  pyogenic 
organism,  as  Donzello 1  maintains.  The  cystitis  which 
sometimes  occurs,  though  it  is  rarely  met  with  apart  from 
catheterization,  may  be  due  to  the  bacilli  contained  in  the 
urine ;  but  the  simple  bacilluria  which  is  frequently  met 
with  usually  exists  without  any  obvious  cystitis. 

Toxins  Of  B.  typhosUS. — Cultures  of  typhoid  bacilli 
do  not  as  a  rule  contain  any  considerable  quantity  of  free 
toxic  matter,  but  the  bodies  of  dead  bacteria  are  them- 
selves poisonous.  Hence  the  toxins  of  the  B.  typhosus 
are  generally  spoken  of  as  "  intracellular."  They  are  very 
unstable  bodies.2  Chantemesse  claims  to  have  succeeded  in 
growing  the  bacilli  in  a  special  medium  containing  spleen- 
pulp  and  bone-marrow,  and  from  this  to  have  obtained  a 
toxin  of  considerable  potency,  which  he  has  used  for  the 
preparation  of  an  antitoxin. 

Aronson3  also  devised  a  medium  in  which  toxins  were 
formed,  but  was  unsuccessful  in  preparing  an  antitoxic 
serum.  Meyer  and  Bergell 4  were  rather  more  successful 
with  the  toxins  of  bacilli  grown  in  a  peptone-broth  pre- 
pared from  the  spleens  of  oxen,  and  regard  the  prospect 
of  a  curative  use  of  their  serum  as  hopeful. 

DIAGNOSIS 

Agglutination.— The  method  of  performing  this  diag- 
nostic test  has  been  fully  dealt  with  in  an  earlier  chapter 
on  serum  diagnosis  in  general  (p.  77),  to  which  reference 
should  be  made,  so  that  it  is  only  necessary  now  to  point 
out  the  fallacies  which  surround  the  test  when  applied  to 
typhoid  infections. 

1  Lo  Sperimentale,  1901,  Iv.  670. 

-  Macfadyen,  Brit.  Med.  Journ.,  1906,  i.  905. 

»  Berlin,  klin.  IToch.,  1907,  p,  572- 

<  Ibifi.,  May  6. 


DIAGNOSIS   OF   ENTERIC   FEVER         231 

Sources  Of  error. — (1)  Apart  from  the  possibility  of 
error  due  to  a  spurious  appearance  of  agglutination,  it 
must  be  borne  in  mind  that  a  certain  number  of  normal 
individuals,  who  have  never  suffered  from  enteric  fever, 
possess  a  serum  with  some  clumping  power  over  typhoid 
bacilli,  while  not  all  patients  suffering  from  the  fever 
present  the  reaction.  Thus  Lobiesen1  found  that,  out 
of  350  cases  which  were  clinically  enteric  fever,  328 
reacted  positively  to  the  Widal  test  with  a  dilution  of  1:  50  ; 
17  agglutinated  in  a  dilution  of  1  :  10  or  1  :  25 ;  two  cases 
reacted  only  at  1  :  5 ;  and  two  failed  to  react  at  all.  The 
great  majority  of  the  patients  (289)  gave  a  positive  reaction 
within  the  first  two  days  after  admission.  Of  151  patients 
suffering  from  diseases  other  than  enteric  fever,  in  whom 
there  was  yet  a  suspicion  that  the  malady  might  be  of 
this  nature,  four  reacted  positively  in  dilution  of  1  :  25,  two 
at  1  :  10,  and  123  were  negative  at  this  dilution.  Of  the 
first  four,  three  were  proved  by  necropsy  to  be  suffering 
respectively  from  acute  tuberculosis,  retroperitoneal  abscess, 
and  calculous  pyelitis  with  tubercular  meningitis.  Of  61 
healthy  persons  who  had  not  had  enteric  fever,  one  reacted 
positively  in  dilution  of  1  :  25,  and  eight  at  1  :  10.  Lobiesen 
believes  that  a  positive  reaction  in  a  dilution  of  1  :  50  is 
pathognomonic  of  enteric  fever,  but  that  absence  of  the 
agglutination  does  not  exclude  the  existence  of  the  disease. 
Blanchi,2  among  167  patients  with  enteric  fever,  found  three 
cases  which  did  not  react  to  the  test.  The  diagnosis  was 
confirmed  by  necropsy. 

Rolleston3  in  South  Africa  found  that  the  test  was  posi- 
tive in  only  64'5  per  cent,  of  his  cases,  and  thinks  that  the 
low  percentage  may  be  accounted  for  by  some  difference  in  the 
strain  of  bacilli  used  for  the  test-cultures,  as  compared  with 
the  organisms  which  had  infected  the  patients.  Kohler4 

1  Zeit.  f.  Jtlin.  Med.,  Bd.  xliii.,  Hft.  1  and  2. 
~  Giornale  Medico  del  Eegio  Exercito,  1901,  No.  5. 
3  Brit.  Med.  Journ.,  1901,  ii.  1084. 
<  Munch,  med,  Woch,,  1903,  p.  1379. 


232       SERUMS,    VACCINES,    AND    TOXINS 

found  that  among  100  patients  suffering  from  diseases  other 
than  enterica  12  gave  a  reaction  in  dilutions  of  1  :  20. 
Among  these  12,  one  agglutinated  at  1  :  50,  two  at  1  :  40, 
and  three  at  1  :  30.  Hence  it  appears  that  even  an  agglu- 
tination reaction  in  a  dilution  of  1 : 50  is  not  a  definite 
proof  of  the  existence  of  enteric  fever. 

(2)  Again,    it   has    been   frequently   noticed,   and    the 
present  writers  have  had  many  opportunities  of  observing, 
that  in   some  severe  and  fatal  cases   of  enteric   fever,  in 
which    the    diagnosis    is    subsequently  confirmed   by   post- 
mortem   examination,    no    agglutinative    power    is    found 
throughout    the    illness.     The  absence    of  agglutination  is 
parallel    to    the    absence    of  resistance   exhibited    by    the 
patients  towards  the  infective  agent. 

(3)  The  clumping  power  of  the  serum  is  not  developed 
at  the  beginning  of  the  attack.     The  exact  period  at  which 
it  may  be  looked  for  is  not  certain,  but  many  observations 
have  shown  that  during  the  first  week  or  even  ten  days  an 
absence  of  agglutinative  power  is  rather  the  rule  than  the 
exception.     Brion  and  Kayzer,1  however,  find  the  reaction 
positive  in  the  first  week  in  50  per  cent,  of  all  cases. 

(4)  The    serum  of   persons  who  have  been   inoculated 
against  typhoid  fever  (p.  246)  will  contain  agglutinins  for 
a  considerable  time  after  this  procedure  ;  the  test  as  applied 
to  a  "  chance  "  sample  of  serum  is  therefore  useless  in  such 
patients  as  a  criterion  of  a  suspected  attack  of  enteric  fever. 

(5)  Certain    other  infective   and   general    diseases   are 
apparently  capable  of  producing  substances   in  the  serum 
which  will  agglutinate  typhoid  bacilli.     Infection  with  B. 
coli  communis  seems  to  produce  this  effect  in  some  cases.2 
Allusion   has   already   been  made    to   the    experiments  of 
Posselt  and  Sagasseiy"  who  found  increased  clumping  power 
towards  B.  typhosus  in  cases  of  dysentery. 

1  Dent.  Arch.f.  klin.  Meet.,  Ixxxv.,  Hft.  -">  and  6. 

2  Cf.  Lubowski  and  Steinberg,  ibid.,  1904,  p.  396  (proteus.jnfection, 
stiphylococei,  etc.). 

3  Seep.  81. 


DIAGNOSIS   OF   ENTERIC   FEVER         233 

Morgan l  found  that  of  six  cases  of  eerebro-spinal 
meningitis,  three  gave  a  "  Widal  "  reaction  when  the  serum 
was  diluted  1  :  50,  and  one  produced  a  definite  but  less 
marked  agglutination. 

The  effect  of  jaundice  in  causing  agglutination  was 
first  pointed  out  by  Grtinbaum,2  and  has  been  confirmed 
by  other  observers.  The  reaction  does  not  seem  to  be 
manifested  in  all  cases  of  jaundice,  but  it  may  occur  with 
sufficient  frequency  to  cause  us  to  regard  the  test  as  un- 
reliable when  this  condition  is  present.  Bile  itself  does 
not  appear  to  agglutinate  the  bacilli  in  all  cases,  but  in 
certain  individuals  and  conditions  of  health  it  may  pro- 
duce the  reaction.  The  exact  body  which  is  active  in 
this  way  is  not  known,  but  its  effect  is  analogous  to  the 
action  of  formalin  and  other  chemical  substances.  It 
must,  however,  be  borne  in  mind  that  infection  of  the 
biliary  passages  with  B.  typhosus  is  not  uncommon,  and 
that  the  jaundice  may  be  a  result  of  this — the  occurrence 
of  the  reaction  thus  being  the  "  exception  that  proves  the 
rule." 

(6)  All  strains  of  B.  typhosus  are  not  agglutinated  with 
equal  facility.     It  is  therefore  necessary  to  make  use  of  a 
culture  in  which  the  bacilli  have  been  proved   to  possess 
this  faculty.     Klein  finds  that  culture   of   the   bacilli  on 
gelatin    induces  greater    agglutinative  properties,  and  ad- 
vises the  use  of  such  cultures  emulsified  with  salt-solution. 

(7)  Kraus3  finds  that  the    effect  of  pneumonia  is  to 
inhibit  the  agglutinative  power.     This  may  be  demonstrated 
by  adding  the  serum  of  a  pneumonic  patient  to  that  of  one 
suffering  from  enteric  fever.     The  coexistence  of  pneumonia 
with  enteric  fever  would,  therefore,  theoretically  prevent  the 
appearance  of  WidaFs  reaction,  and  the  test  would  be  use- 
less as  a  means  of  differentiating  the  two  diseases.     These 

1  "  An  Account  of  an  Outbreak  of  Spotted  Fever,  etc."     Swansea 
1909. 

2  Munch,  med.  Woch.,  1897,  No.  13. 

3  Zeit.f.  Jfei/kranM.,  Bd.  xxi.,  Heft  5. 


234       SERUMS,   VACCINES,    AND   TOXINS 

observations,  however,  need  further  confirmation.  Kissel 
and  Mann,1  on  the  other  hand,  found  that  two  cases  of 
croupous  pneumonia  gave  the  reaction,  though  they  were 
not  suffering  from  enteric  fever. 

Value  of  the  test. — On  the  whole  it  may  be  said 
that  the  reaction  is  not  infallible,  but  has  a  margin  of  error 
of  perhaps  5  percent  Abbott2  studied  4,154  cases,  and 
found  the  error  only  2-8  per  cent.  We  believe  that,  with  a 
time-limit  of  thirty  minutes,  a  positive  reaction  in  a  dilution 
of  1  :  20  implies  either  the  existence  of  enteric  fever  or  a 
past  attack  within  recent  years ;  a  reaction  in  a  dilution 
of  1  :  50  implies  either  existing  disease  or  a  very  recent 
attack ;  and  a  reaction  in  a  dilution  of  1  :  200  is  positive 
proof  of  present  typhoid  infection. 

The  test  is  said  to  be  of  special  value  in  the  case 
of  children.  Gershel,3  among  84  cases  of  enteric  fever  in 
infants,  found  the  reaction  positive  in  81,  while  it  was 
negative  in  115  patients  who  were  suffering  from  other 
diseases.  Other  writers  also  agree  with  this  estimate  of 
the  use  of  the  test  in  children.4 

It  is  generally  stated  that  the  agglutination  reaction 
is  of  no  use  as  a  means  of  prognosis.  This  is  probably  true 
as  far  as  the  rapidity  and  completeness  of  the  clumping  are 
concerned ;  but  there  is  reason  to  think  that  a  case  which, 
clinically,  is  almost  certainly  a  severe  attack  of  enteric 
fever,  but  which  gives  no  reaction,  is  likely  to  end  fatally, 
as  the  absence  of  agglutinative  power  in  such  instances 
seems  to  be  associated  with  an  absence  of  resistance. 

Persistence    of  the   reaction.  —  H.    French    and 

Louisson 5  find  that  as  a  rule  the  reaction  disappears 
rapidly  after  the  patient's  recovery,  but  that  in  excep- 
tional cases  (7 '5  per  cent.)  it  may  remain  for  years  (eight 

1  Munch,  med.  Woch.,  May  2,  1899. 

2  Philadelphia  Mid.  Journ.,  Feb.  25,  1899. 

3  Med.  Record,  Xov.  26,  1901. 

4  Josias  and  Toilemer,  Med.  Press  and  Circ.,  Aug.  26,  1003,  p.  217. 

5  Guy's  Hasp.  Repts.,  1907,  bci.  235. 


SERUM  TREATMENT  OF  ENTERIC  FEVER   235 

years  and  probably  longer).  Gaehtgens  l  found  the  reaction 
positive  in  one  case  thirty-five  years  after  an  attack. 

Mandelbaum's  reaction.2 — This  modification  of  the 
agglutination  reaction  consists  in  growing  the  bacilli  in 
bouillon  along  with  a  little  immune  serum.  The  organisms 
then  form  chains  and  clumps,  whereas  if  the  serum  used  is 
not  immune  they  develop  as  usual.  This  reaction  may  be 
used  as  a  test  for  the  disease.  Ast 3  considers  it  useful  for 
the  discovery  of  "  carriers,"  but  admits  that  an  incomplete 
reaction  may  occur  with  the  serum  of  normal  persons. 

Ophthalmic  reaction. — Chantemesse4  suggests  as  a 
test  the  use  of  a  powder  derived  from  the  bacilli,  which  is 
applied  to  the  conjunctiva  and  causes  inflammatory  reaction 
in  patients  suffering  from  enteric  fever,  just  as  tuberculin 
does  in  tuberculous  subjects. 

This  test  has  been  tried  by  Kraus,  who  finds  that  60 
per  cent,  of  patients  with  enteric  fever  react  positively. 
Cohn  and  Entz  find  that  healthy  persons  may  also  give 
a  reaction.5 

Meroni  holds  that  a  negative  result  after  twenty-four 
hours  excludes  enteric  fever,  while  a  positive  reaction  raises 
a  probability,  but  not  a  certainty,  of  typhoid  infection.6 

SERUM    TREATMENT 

Chantemesse'S  serum. — By  means  of  the  toxins 
prepared  as  already  mentioned  (p.  230),  Chantemesse  7  has 
produced  a  serum  for  the  cure  of  enteric  fever.  It  is  pre- 
pared by  inoculation  of  horses  with  the  toxin  in  the  usual 
manner.  The  process  of  inoculation  is  long  and  tedious,  as 
very  small  doses  must  be  employed  at  first;  otherwise  the 

1  See  lancet,  1907,  i.  1363. 

2  Miinch.  med.  Woch.,  1910,  p.  855. 

3  Ibid.,  p.  2634. 

4  Dent.  med.  Woch.,  1907,  p.  1572. 

5  Sec  Wolff  Eisner,  op.  cit.,  sub.  Tuberculin. 
8  Miinch.  med.  Woch.,  1908,  No.  26. 

?  la  Presse  Med.,  1901,  No.  93,  p.  285. 


236       SERUMS,    VACCINES,    AND    TOXINS 

horses  may  be  killed  by  the  toxin — Chantemesse  speaks  of 
losing  several  in  the  course  of  his  investigations.  The 
immunization  of  the  animals  was  begun  in  1896,  whereas  the 
first  experiments  with  the  serum  on  patients  suffering  from 
enteric  fever  were  apparently  carried  out  in  1900  (?).  It 
may  be  concluded  that  at  least  two  years  were  consumed 
in  the  preparation  of  the  remedy.  The  results  of  this 
method  of  treatment,  as  recorded  by  its  author,  are  very 
encouraging.  It  is  difficult  to  ascertain  the  average  mor- 
tality of  the  disease,  as  it  varies  much  in  severity  in  different 
years,  the  reasons  for  this  variability  not  being  known.  In 
Paris,  in  the  years  1899  and  1900,  the  death-rate  was  18-5 
per  cent. ;  in  1901,  from  January  to  October,  it  was  29  per- 
cent, among  371  patients  treated  in  nine  hospitals.  Chante- 
messe treated  100  patients  by  his  method,  with  six  deaths. 
All  those  who  were  treated  before  the  tenth  day  recovered. 
Of  those  treated  later,  three  cases  died  of  perforation  of  the 
intestine ;  one  (injected  on  the  twenty-first  day  of  the 
illness)  of  pneumonia ;  one  (injected  on  the  twenty-fifth 
day)  of  hypei-pyrexia,  and  one  of  a  sacral  bedsore  acquired 
before  admission  to  hospital.  Two  subsequent  cases,  which 
were  injected  on  admission  to  hospital  in  a  moribund 
condition,  are  not  included  in  the  statistics. 

According  to  some  more  recent  statistics,1  while  the 
mortality  in  fourteen  hospitals  where  the  serum  was  not 
used  amounted  to  17 '3  per  cent.  (3,595  cases,  with  763 
deaths),  in  the  Bastion  Hospital,  where  the  serum  was 
used,  the  mortality  was  only  3'7  per  cent.  (712  cases, 
27  deaths). 

Chantemesse  gives  charts  of  some  of  the  cases  treated 
by  the  serum,  showing  that  the  injections  are  followed  by 
a  rapid  fall  of  temperature  and  improvement  in  the  pulse. 
The  earlier  the  serum  is  administered,  the  more  marked  is 
the  effect.  If  the  remedy  be  given  before  the  eighth  day 
in  cases  of  ordinary  severity,  the  disease  may  be  cut  short 
within  a  period  of  a  few  days.  Sometimes  the  first  improve- 
1  Chantemesse,  Paris  Med.  Jouni..  1906,  i.  3. 


CHANTEMESSE'S    SERUM  237 

ment  is  not  maintained,  and  the  temperature  rises  again 
on  a  later  day  ;  in  such  instances  a  second  injection  should 
be  given,  and  may  be  followed  by  rapid  recovery.  The 
accompanying  charts,  modified  from  those  given  in  Chante- 
messe's  article,  show  the  results  obtained  in  some  of  his 
cases  (Charts  1  and  2). 

Besides  the  effects  on  the  pulse  and  temperature,  the 
serum  has  a  beneficial  influence  on  the  excretion  of  urine, 


CHART  1.  —ILLUSTRATING  THE  EFFECTS  OF  CHANTEMESSE'S  SERUM. 

which  increases  in  quantity  as  the  pulse  and  temperature 
fall.  Albuminuria  is  not  caused  by  the  serum  itself — a 
point  in  which  it  appears  to  differ  from  diphtherial  anti- 
toxin, which  is  accused  of  causing  the  appearance  of 
albulmin — indeed,  in  cases  in  which  there  is  already 
albuminuria,  this  may  decrease  as  the  result  of  serum 
treatment.  A  hyperleucocytosis  is  produced  in  the 
blood,  in  opposition  to  the  leucopenia  (defective  number 


238       SERUMS,    VACCINES,    AND    TOXINS 

of   leucocytes)    which   is   characteristic    of    enterica.     The 
leucocytosis  is  exactly  similar    to  that  which  is  normally 


OIJ.03 


CHANTEMESSE'S    SERUM  239 

seen  in  convalescents  from  enteric  fever.  The  myelocytes 
which  are  present  during  the  disease  disappear,  while  the 
other  varieties  of  cells  (lymphocytes,  eosinophile  cells,  and 
multinucleate  leucocytes)  increase  to  their  normal  amount : 
they  may  even  be  in  excess  at  first. 

Complications  are  rare  in  cases  treated  with  serum, 
but  are  not  entirely  absent.  Chantemesse  noted  in  his 
first  series  one  case  of  perforation  and  one  of  pneumonia, 
both  fatal  ;  and  others  of  otitis  media,  haemorrhage,  and 
phlebitis,  all  of  which  recovered.  Probably  the  serum  has 
no  direct  influence  on  the  occurrence  of  complications  ; 
these  are  due  to  other  organisms,  which  are  unaffected 
by  it ;  but  if  it  control  and  cut  short  the  typhoid  infec- 
tion, it  must  indirectly  diminish  the  risk  of  secondary 
lesions. 

The  serum  is  injected  under  the  skin  of  the  forearm  in 
the  neighbourhood  of  the  usual  point  for  venesection.  The 
skin  and  the  syringe  are  carefully  sterilized,  and  the  veins 
of  the  part  must  not  be  wounded.  The  ordinary  dose  of 
serum  is  10  or  12  c.c.  A  second  dose  may  be  given  at  the 
end  of  eight  or  ten  days,  if  the  temperature  has  risen 
again,  or  if  there  is  any  other  indication  ;  the  second  dose 
may  be  smaller  than  the  first — 4  or  5  c.c.  There  are  two 
indications  for  giving  a  smaller  dose  than  the  above- 
mentioned  as  a  first  injection,  viz.  (1)  when  the  patient 
comes  under  treatment  in  quite  the  early  days  of  the 
disease  (fifth  or  sixth) ;  and  (2)  when  the  disease  has 
already  lasted  for  a  considerable  time,  and  the  general  in- 
toxication is  profound.  In  these  cases  5  to  8  c.c,  are 
sufficient. 

The  injections  are  followed  by  a  reaction,  shown  by  a 
rise  of  temperature,  which  quickly  falls  again.  Chante- 
messe attributes  this  reaction  to  the  great  destruction  of 
the  bacilli  which  is  induced  by  the  serum,  and  to  the  conse- 
quent absorption  of  a  large  dose  of  their  toxins.  He  con- 
siders his  serum  to  be  bactericidal  as  well  as  antitoxic.  It 
is  difficult  to  accept  this  explanation  in  view  of  the  nature 


240       SERUMS,    VACCINES,    AND    TOXINS 

of  the  serum,  which,  from  its  manner  of  preparation,  should 
be  purely  antitoxic,  and  not  bactericidal.  An  additional 
argument  against  Chantemesse's  view  may  be  derived  from 
the  fact  that  the  injection  of  this  serum  does  not  increase 
the  agglutinative  power  of  the  blood.1 

Along  with  the  serum,  other  treatment  should  not  be 
omitted,  especially  reduction  of  temperature  by  baths,  and 
the  plentiful  supply  of  liquid  nourishment  to  the  patient. 
It  may  be  necessary  to  stop  milk-feeding  for  a  time  after 
the  injection,  as  milk  often  appears  to  be  ill  digested ; 
it  may  be  resumed  again  as  the  temperature  falls. 

No  bad  effects  are  produced  by  the  serum,  with  the 
exception  of  slight  erythema,  which  only  appeared  in  two 
of  Chantemesse's  100  cases. 

Besides  Chantemesse  himself,  Boutleux  ~  treated  1 5 
cases  with  the  serum ;  all  of  these  recovered.  Josias 3 
reports  50  cases  in  children  in  which  he  used  the  remedy. 
Among  them  there  were  two  deaths,  a  mortality  of  4  per 
cent.  Simultaneously,  in  other  children's  hospitals  in  Paris 
the  mortality  was  14-2  per  cent.  He  confirms  the  benefit 
derived  from  early  administration  of  the  serum,  and  states 
that,  though  relapses  occurred  in  four  cases,  they  were  mild 
in  type.  The  doses  given  amounted  to  1  c.c.  for  each  30 
kilogrammes  of  body-weight.  In  a  certain  proportion  of 
cases  in  young  children  pain  in  the  bowels  wiis  complained 
of,  some  days  after  the  injections ;  and  this  was  at  times  so 
severe  as  to  create  a  suspicion  of  peritonitis.  No  ill  effects, 
however,  actually  ensued.  Osteitis  and  periostitis  occur- 
ring during  convalescence  from  enteric  fever  are  said  to  be 
benefited  by  the  serum. 

Before  we  can  pronounce  a  definite  verdict  on  the  value 

1  Josias  and  Tollemer,  Congress  of  Madrid,  1903.    La  Presse  Med., 
June  24, 1903,  p.  468. 

2  Quoted  by  Chantemesse,  loc.  cit. 

3  International  Medical  Congress  of  Madrid.     See  Med.  Press  and 
Circular,  July  29,   1903,  p.   109  ;    Ann.  de  Med.  et   Chir.  Infantiles, 
1903,  No.  11,  p.  367. 


ANTITYPHOID    SERUM  241 

of  this  serum  it  will  be  necessary  to  wait  until  a  larger 
number  of  physicians  have  used  it  in  the  treatment  of 
enteric  fever  and  recorded  their  results.  Up  to  the  present 
day,  this  preparation  does  not  seem  to  have  been  exten- 
sively used  in  treatment.  Chantemesse's  results,  however, 
are  very  encouraging,  although  712  cases  form  far  too  small 
a  material  on  which  to  base  an  opinion,  since  the  disease  is 
so  variable  in  its  severity  at  different  times  and  different 
places. 

Other  serums. — "W.  V.  Shaw1  obtained  toxic  material 
by  "digesting"  B.  typhosus  in  normal  blood-serum.  He  in- 
jected this  into  a  horse  and  obtained  a  serum  which  had 
some  protective  power,  while  the  injections  were  at  first 
followed  by  a  fall  in  the  bactericidal  property  of  the  horse's 
serum — "  negative  phase."  From  this  it  would  appear  that 
the  serum  is  antibacterial  rather  than  antitoxic,  and  hence 
comparable  with  that  mentioned  in  the  following  section 
rather  than  with  Chantemesse's  preparation. 

Macfadyen  immunized  a  horse  by  injecting  it  with 
endotoxin,  prepared  by  grinding  up  typhoid  bacilli  at  the 
temperature  of  liquid  air,  and  showed  that  the  serum  was 
both  antitoxic  and  bactericidal.  Hewlett3  continued  the 
observations  and  employed  the  serum  in  9  cases  of  enteric 
fever;  he  concluded  that  8  patients  were  benefited  and 
that  in  2  of  these  the  course  of  the  fever  was  decidedly 
shortened.  Goodall  3  tried  it  in  26,  and  Bruce  4  in  5  cases  ; 
benefit  being  observed  in  9  of  these  last  31  cases — not  a 
very  striking  achievement. 

Rodet  and  Lagriffoul  5  state  that  by  injecting  living 
bacilli  they  get  an  antitoxic  serum  which  they  used  with 
advantage  in  27  cases  of  enteric  fever.  To  be  of  use  the 
remedy  must  be, given  before  the  eleventh  day. 

1  Lancet,  1903,  ii.  948. 

2  Proc.  Royal  Soc.  Ned.,  1909,  ii.,  Medical  Section,  p.  245. 

3  Op.  cit.,  p.  254. 

4  Op.  cit.,  p.  262. 

5  Compt.  Rend.  Soc.  de  Blol,  1910,  Ixviii.  GOt. 
Q 


242       SERUMS,   VACCINES,    AND    TOXINS 

Kraus  and  Stenitzer l  prepared  an  anti-endotoxic  serum 
which  proved  beneficial  in  doses  of  30-40  c.c.  They  also 
insist  on  administration  early  in  the  disease. 

BACTERICIDAL    SKHl'M 

Antityphoid  serum. — The  serum  of  convalescents 
from  enteric  fever  is  bactericidal  and  not  antitoxic  in  its 
action  ;  and  most  of  the  serums  on  the  market,  which  are 
professedly  "  antityphoid,"  are  of  similar  nature.  They  are 
prepared  by  immunizing  a  horse  with  the  actual  bacilli  of 
enteric  fever.  Chantemesse <<J  alludes  to  experiments  made 
by  Widal  and  himself  in  order  to  produce  a  serum  of  this 
nature,  but  he  speaks  of  the  results  obtained  as  unsatis- 
factory. In  1898  Bokenham3  prepared  an  antityphoid  serum 
by  inoculating  a  horse  with  filtered  cultures  of  the  bacilli 
and  then  with  the  dead  bodies  of  the  organisms  them- 
selves; he  found  that  the  serum  acted  as  a  protective  to 
rabbits. 

Krumbein  4  used  for  inoculation,  first,  filtered  cultures, 
then  bacteria  killed  by  carbolic  acid.  The  bacilli  were 
grown  for  fourteen  days  in  broth,  to  which  0'5  per  cent, 
of  phenol  had  been  added.  The  cultures  were  injected 
subcutaneously.  Considerable  constitutional  disturbance 
may  be  produced,  and  abscesses  may  also  form  at  the  seat 
of  injection.  After  a  point  had  been  reached  at  which 
150  c.c.  were  given  for  a  dose,  the  serum  of  the  horse 
was  drawn  off  and  used.  In  subsequent  experiments  the 
living  bacilli  were  injected  during  the  later  periods  of  the 
immunizing  process. 

It  appears  that  the  typhoid  bacillus  is  modified  to  some 
extent  by  its  surroundings,  and  that  different  strains  of 
bacteria  thus  produced,  taken  from  different  cases,  may  act 
variably  towards  a  particular  serum.  In  other  words,  a 

1Deut,  med.  Woch  ,  1911,  p.  .577. 

2  Loc.  cit. 

3  Trans.  Path.  Soc.  Lond.,  1898,  p.  373. 

4  Ainlcy  Walker,  Jonrn.  of  J'atftol.  aid  Jinctei-U/l.,  1901.  vii.  '_';>]. 


ANTITYPHOID    SERUM  243 

serum  is  found  to  have  a  more  marked  effect  on  the  strain 
of  bacilli  from  which  it  was  prepared.  It  is,  therefore,  advis- 
able to  make  use  of  several  strains  in  the  immunization  of 
the  horse.  The  serum  of  the  horse  becomes  highly  agglu- 
tinative towards  the  bacilli  as  the  result  of  the  treatment. 
Walker  considers  that  the  agglutinative  power  increases 
practically  pan  passu  with  the  protective  property,  but  that 
the  two  are  not  directly  proportional  to  one  another.  He 
finds  that  the  uerum  prepared  as  above  is  antitoxic  as  well 
as  antibacterial.  He  also  makes  the  suggestion  that  the 
horse  should  be  immunized  against  the  ./?.  coli  communis  as 
well  as  against  the  E.  typhosus,  or  that  some  "  anti-coli " 
serum  should  be  added  to  the.  antityphoid  serum  for 
therapeutic  use.  Rodet  and  Lagriffoul1  also  state  tha't 
after  the  injection  of  living  bacilli  the  serum  obtained  is 
antitoxic.  They  advise  the  use  of  such  serum,  which 
should  be  administered  before  the  eleventh  day  of  the 
disease. 

Experience  at  the  present  day  is  not  very  favourable  to 
the  use  of  an  antibacterial  serum  in  the  treatment  of  enteric 
fever.  The  present  writers  have  seen  the  ordinary  serum 
which  is  on  the  market  tried  in  several  cases  of  the  disease, 
but  in  none  of  them  was  it  possible  to  be  sure  of  any  definite 
benefit  accruing  to  the  patient.  Relapse  was  not  prevented 
by  the  use  of  the  serum.  Walker  concludes  that  "  most 
antityphoid  sera  which  have  been  prepared  have  given  no 
marked  assistance  in  the  treatment  of  the  disease  in  man." 
Reasons  for  this  have  been  already  suggested.  Moreover, 
in  the  later  stages  of  the  disease  the  bacilli  are  for  the 
most  part  localized  in  the  alimentary  canal,  and  the  toxins 
are  probably  absorbed,  as  in  cholera,  without  any  further 
escape  of  the  organisms  into  the  general  circulation.  If  so, 
it  may  be  difficult  for  the  antibacterial  serum  to  reach 
them  ;  and  attention  should  be  turned  to  the  preparation 
rather  of  an  antitoxic  serum  than  of  one  that  is  germicidal. 
In  the  second  place,  it  may  be  that  the  copula  or  immune 
1  Compt.  Rend.  Soc.  de  Siol.,  1910,  Ixviii.  604. 


244       SERUMS,    VACCINES,    AND    TOXINS 

body  present  in  horse-serum  is  not  capable  of  uniting  with 
the  alexine  or  complement  found  in  human  blood,  in  which 
case  no  bacteriolysis  would  be  produced.  It  has  further  to 
be  remembered  that  enteric  fever  is  characterized  by  a 
gradual  onset,  so  that  it  is  seldom  recognized  until  it  has 
lasted  at  least  five  or  six  days.  Hence  the  first  requisite  in 
the  administration  of  any  kind  of  serum — early  injection — 
is  generally  impossible,  and  it  is  unreasonable  to  expect  as 
good  results  to  occur  as  can  be  obtained  in  diphtheria.  It 
is  possible  that  by  the  time  the  serum  is  used  there  may 
be  a  deficiency  of  complement  in  the  patient's  blood,  and 
that  bacteriolysis  may  not  occur,  even  if  the  copula  sup- 
plied be  suitable.  Finally,  if  the  destruction  of  the  bacilli 
is  brought  about  by  the  interaction  of  the  serum  with  the 
leucocytes  of  the  patient,  the  leucopenia  characteristic  of 
the  disease  may  militate  against  the  efficacy  of  the  remedy. 

ANTITYPHOID  EXTRACT  OF  JEZ 

Jez1  starts  with  the  assumption  that  the  serum  obtained 
from  immunized  animals  is  bactericidal  and  not  antitoxic, 
and  that  such  a  serum  is  of  no  value  for  the  treatment  of 
enteric  fever.  Some  other  method  of  conferring  immunity 
must  be  tried.  Now,  Wassermann  found  that  the  spleen, 
bone-marrow,  and  lymphatic  glands  of  an  immunized  animal 
had  protective  properties ;  and  Jez  has  made  use  of  this 
discovery  to  prepare  a  substance  which  he  considers  to  be 
curative  of  enteric  fever.  He  makes  his  antityphoid  ex- 
tract by  rubbing  up  in  a  mortar  the  brain,  spinal  cord, 
spleen,  marrow,  etc.,  of  immunized  rabbits,  and  adding  to 
the  pulp  thus  obtained  saline  solution,  to  make  an  emulsion, 
along  with  a  small  amount  of  alcohol  and  of  carbolic  acid. 
The  fluid  is  filtered  after  it  has  stood  for  a  time,  to  ensure 
solution  of  the  protective  bodies.  In  later  experiments  Jez 
added  also  a  certain  proportion  of  pepsin,  presumably  in 
order  to  facilitate  solution. 

The  filtered  fluid  is  antitoxic,  but  not  agglutinative  or 
1  Wicn.  med.  Woch.,  Feb.  18,  1899,  p.  31G 


JEZ'S    ANTITYPHOID   EXTRACT  245 

bacteriolytic.  As  a  remedy  for  enteric  fever,  it  is  given  by 
the  mouth ;  but  if  for  any  reason  this  is  impossible,  it 
can  be  administered  subcutaneously.  A  tablespoonful  con- 
stitutes a  dose,  which  may  be  given  every  two  hours,  or 
more  frequently.  Considerable  quantities  are  needed  for 
each  case,  reaching  a  pint  or  more. 

Jez  finds  that,  as  the  result  of  treatment  with  his  ex- 
tract, the  temperature  falls,  the  pulse  improves,  and  the 
general  condition  of  the  patient  is  ameliorated.  Diarrhoea 
is  usually  checked.  Sometimes  sweating  is  produced  by  the 
action  of  the  remedy.  Jez  records  the  trial  of  the  extract 
in  eighteen  cases,  all  of  which  recovered. 

These  results  are  confirmed  by  Kluk-Kluczycki,1  who 
finds  that  the  fever-reducing  effect  is  manifested  within 
twenty-four  hours,  an  apyrexial  condition  being  often 
reached  within  three  weeks — which  may  also  occur  even  in 
untreated  cases.  Eichhorst3  has  also  tried  the  extract  in 
a  small  number  of  cases  (12),  and  is  favourably  impressed 
with  the  results  produced  ;  and  a  similar  verdict  is  pro- 
nounced by  du  Mesnil  de  Rochemont5  and  by  Einhorn,4 
who  observed  a  reduction  of  fever  and  some  mental  im- 
provement. On  the  other  hand,  Pometta5  found  Jez's 
preparation  quite  useless. 

The  use  of  Jez's  extract  does  not  seem  to  have  become 
at  all  general,  so  that  there  is  not  sufficient  information 
available  upon  the  subject  to  enable  us  to  form  a  satis- 
factory judgment  as  to  its  efficacy.  The  idea  underlying  it 
is  not  to  be  neglected,  as  Wassermann's  experiments,  con- 
firmed by  Jez,  seem  to  point  to  the  existence  of  a  protec- 
tive principle  in  the  organs  of  immunized  animals  (cf.  p.  212, 
Plague).  This  does  not,  however,  necessarily  imply  its 
value  as  a  cure  for  the  disease. 

1  Wien.  Urn.  Woch.,  1901,  No.  4,  p.  84. 

2  TJierap.  Monatsh.,  1900,  p.  115. 

3  Ibid.,  Jan.,  1904,  p.  13  (7  cases). 

4  Med.  Record,  Jan.  16,  1904,  p.  81  (3  cases). 

5  Wien.  med.  Woch.,  1901,  No.  46. 


246       SERUMS,   VACCINES,    AND   TOXINS 

ANTITYPHOID  INOCULATION 

Wright's  vaccine. — Experiments  were  made  by  Pfeitier 
and  Kolle  l  in  1896  as  to  the  effect  of  inoculating  patients 
with  cultures  of  typhoid  bacilli ;  but  although  it  was  shown 
that  the  blood  of  those  so  treated  had  a  protective  influence 
on  guineapigs,  no  practical  use  seems  to  have  been  made 
of  the  method.  It  is  to  Wright  that  the  practical  intro- 
duction of  vaccination  as  a  means  of  prophylaxis  against 
enteric  fever  is  entirely  due. 

The  vaccine  originally  used  by  Wright  ~  consisted  of 
cultures  of  B.  typkosus  in  broth,  grown  for  four  weeks, 
and  then  sterilized  by  heating  for  ten  to  fifteen  minutes 
at  60°  C.  For  this  vaccine  a  large  number  of  separate 
cultures  are  mixed  together,  so  as  to  obtain  a  fluid  of 
the  standard  strength.  Special  flasks  also  are  used  for 
the  preparation  of  the  cultures,  in  order  to  facilitate  the 
subsequent  mixing.  The  bacterial  content  of  the  mate- 
rial can  be  roughly  gauged  by  its  opacity  to  light,  for 
the  measurement  of  which  Wright  devised  an  ingenious 
arrangement.  A  small  amount  of  carbolic  acid  or  lysol  is 
subsequently  added  to  ensure  sterility  and  the  preservation 
of  the  vaccine. 

The  dose  used  for  an  injection  in  man  was  the  minimal 
lethal  dose  for  a  guineapig  weighing  100  grm.,  or  rather 
the  proportional  fraction  of  the  dose  which  proves  fatal  to 
one  of  the  ordinary  weight  (250  to  300  grm.).  A  virulent 
culture  will  contain  the  requisite  quantity  in  0'5  c.c.,  but 
with  weaker  vaccine  it  is  necessary  sometimes  to  give  as 
much  as  1'5  c.c.  Wright  also  used  a  vaccine  consisting  of 
agar-cultures  of  the  bacilli  grown  for  twenty- four  hours 
and  sterilized  at  60°  C.,  a  modification  still  preferred 
by  many  workers  as  being  less  toxic  than  the  broth- 
vaccines. 

The  injections  are  followed  by  redness  and  pain  at  the 

1  Deut.  med.  Wr.cli.,  1896. 

2  Lancet,  1901,  i.  150. 


ANTITYPHOID    INOCULATION  247 

site  of  inoculation,  with  some  lymphangitis  and  enlarge- 
ment of  neighbouring  glands.  There  may  be  nausea  and 
even  vomiting,  and  there  is  considerable  feeling  of  illness, 
with  some  rise  of  temperature.  Occasionally  in  a  neurotic 
patient  a  condition  approaching  collapse  is  observed.  These 
symptoms  pass  off  rapidly  without  leaving  any  permanent  ill 
effects,  but  they  are  severe  enough  to  act  as  a  very  real 
deterrent. 

Wright  found,  later,  that  better  results  were  obtained 
if  the  vaccine  was  prepared  from  twenty-four-hour  cultures 
grown  upon  the  surface  of  agar,  and,  after  em  unification, 
standardized  to  contain  1 ,000  millions  of  typhoid  bacilli  in 
every  cubic  centimetre.  Sterilization  is  effected  by  heating 
for  half  an  hour  at  56°-58°  C.,  and  0'5  per  cent,  lysol  is 
then  added.  The  dose  is  500  or  1,000  millions  of  bacilli. 
Two  injections,  the  first  of  500  and  the  second  (fourteen, 
days  later)  of  1,000  millions,  are,  however,  preferable.  We 
frequently  give  three  doses,  the  first  of  500  millions,  the 
second  of  1,000  millions  after  an  interval  of  ten  days,  and 
the  third  of  1,000  or  2,000  millions  eight  days  after  the 
second.  After  such  injections  the  local  reaction  and 
neighbouring  lymphangitis  are  the  only  resulting  incon- 
veniences. 

The  immediate  result  of  the  vaccination  is  to  produce  a 
lowering  of  the  resistance  offered  by  the  individual  to  in- 
fection by  enteric  bacilli.  If  large  doses  of  the  vaccine  are 
given,  this  fall  in  immunity  may  be  very  marked,  and  may 
last  for  some  weeks.  If  small  doses  are  given,  the  fall  in 
resistance  is  very  slight  and  transitory.  For  these  reasons 
it  is  advisable  to  make  use  of  small  doses,  repeated  if 
necessary,  rather  than  one  large  dose.  It  is  also  im- 
portant not  to  vaccinate  in  the  presence  of  an  epidemic,  as 
such  a  procedure  would  tend  to  make  the  subject  more 
liable  to  contract  the  infection. 

Almost  all  the  statistics  as  to  the  efficacy  of  Wright's 
vaccination  are  derived  from  observations  on  different 
units  of  the-  British  army  in  South  Africa  during  the 


248       SERUMS,    VACCINES,    AND    TOXINS 

Boer  War,  and  in  India,  Egypt,  and  Malta.  On  the 
following  page  are  some  of  the  figures  given  by  Wright 
himself. 

Cayley  l  also  gives  favourable  figures  with  regard  to  the 
use  of  inoculation  in  the  members  of  the  Scottish  National 
Red  Cross  Hospital.  Among  57  inoculated  persons  in  the 
1st  Section  no  attacks  occurred ;  among  82  of  the  2nd 
Section,  the  greater  number  were  inoculated  with  old 
vaccine,  and  five  orderlies  developed  enteric  fever ;  one 
nurse  refused  inoculation,  and  she  also  suffered.  Among 
the  3rd  Section  (20)  all  were  inoculated,  and  no  cases  of 
the  disease  occurred.  Cayley  considers  that  cases  which 
do  occur  in  inoculated  persons  are  milder  and  run  a  shorter 
course  than  in  the  uninoculated. 

Birt2  quotes  his  experience  in  an  epidemic  at  Harri- 
smith.  Among  947  unvaccinated  patients  the  mortality 
was  14-25  per  cent.,  while  of  263  who  had  been  inoculated 
the  death-rate  was  only  6 '8  per  cent.  These  figures  point 
to  the  disease  being  of  a  milder  character  in  those  who 
have  been  vaccinated.  Kuhn3  used  three  inoculations,  and 
found  that  no  "  negative  phase  "  followed  the  third.  He 
records  good  results,  and  states  that  immunity  lasts  for 
one  year.  Bessau4and  Vincent5  also  assert  that  there  is 
no  period  of  increased  susceptibility  (negative  phase)  after 
the  use  of  the  vaccine. 

In  the  United  States  army  the  procedure  consists 
in  giving  three  doses  of  300  millions  into  the  deltoid 
muscle  (Fletcher).6  Inoculation  is  compulsory  on  all 
recruits.  Statistics  show  that  whereas  between  1901  and 

1  Brit.  Med.  Journ.,  1901,  i.  84. 

2  Ibid.,  1902,  i.  75.     Cf.  Ward,  Joiirn.  E.A.M.C.,  1906,  vi.  431. 

a  Abstr.  Centralbl.f.  Bakt.,  I.  Kef.,.  1907,  xl.  602.     Cf.  Eichholz, 
Miinch.  med.  JFoch.,  1907,  p.  777. 
*  Berl.  klin.  Jrocfi.,  1912,  No.  47. 

5  Compt.  Rend.  Acad.  Sci.,  1912,  civ.  784. 

6  Journ.   Amer.  Med.  Assoc.,   April   8,    1911.      Cf.   Phallen  and 
Callison,  Med.  Record,  1911,  Ixxx.  1203. 


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250       SERUMS,   VACCINES,    AND    TOXINS 

1908  the  incidence  of  the  disease  varied  between  3-20 
and  6-99,  with  a  mortality  of  0-27-0-88,  in  1912,  when 
vaccination  was  extensively  practised,  the  figures  were  0'31 
morbidity  and  0'044  mortality  (Revoul).1 

Fox,2  in  India,  uses  two  inoculations  of  500  and  1,000 
millions  respectively,  given  at  an  interval  of  not  more 
than  ten  days.  The  vaccine,  consisting  of  bacilli  killed 
at  a  temperature  of  53°  C.,  should  be  kept  for  three 
weeks  before  use,  but  not  employed  when  it  is  more  than 
three  months  old.  Vaccination  should  be  repeated  after 
two  years. 

Bassenge  and  Mayer 3  suggest  for  purposes  of  vac- 
cination the  use  of  a  clear  fluid  prepared  according  to 
Brieger's  method  by  shaking  typhoid  bacilli  with  distilled 
water  and  filtering.  The  preparation  is  very  stable,  but 
immunity  only  lasts  about  three  months. 

Besredka,4  who  employs  living  typhoid  bacilli  sensitized 
by  the  addition  of  typhoid  amboceptor  from  immune  serum, 
having  inoculated  more  than  15,000  individuals  during  a 
period  of  two  and  a  half  years,  states  that  this  prepara- 
tion not  only  produces  greater  immunity,  but  also  causes 
less  local  and  constitutional  effect  than  the  "  killed " 
vaccine. 

The  experience  gained  during  the  present  European 
War  forms  a  striking  testimony  to  the  value  of  antityphoid 
vaccination  which  has  been  extensively  practised  in  the 
British  army.  Although  the  exact  figures  of  inoculated 
and  uninoculated  are  not  available,  some  battalions  went 
to  the  front  composed  entirely  of  inoculated  men.  On 
January  10,  1916,  in  answer  to  a  question  in  the  House  of 
Commons,  the  Under-Secretary  of  State  for  War  gave  the 
following  figures  in  connection  with  the  distribution  of 
cases  of  typhoid  which  had  occurred  in  the  British  forces 

1  Journ.  Amer.  Med.  Atsoc.,  1913,  Ixi.  666. 
*  Journ.  Trop.  Me d ,  1910,  xiii.  367. 

3  LetU.  med.  Woch.,  May  4,  1905. 

4  Ann.  de  rintt.  Pctteur,  1913,  xviii.  607. 


ANTITYPHOID    INOCULATION 


251 


in  the  field  (the  total  numbers  of  troops  involved  are  not 
permitted  to  appear)  : — 


CASES 

DEATHS 

MORTALITY 

Per  cent. 

Uninoculated     ... 

571 

115 

20-14 

Fully   inoculated    within    two 

vears  (two  doses) 

369 

22 

5-96 

Partially  inoculated  (one  dose) 

210 

13 

6-19 

It  must  be  remembered  that  one  attack  of  enteric  fever 
does  not  protect  against  a  second,  as  was  at  one  time 
supposed.  Experience  in  the  South  African  War  has 
definitely  proved  that  second  attacks  are  not  by  any 
means  rare,  although  they  seem,  as  a  rule,  comparatively 
mild  in  degree.  Hence  vaccination  cannot  be  expected  to 
produce  absolute  immunity,  but,  as  might  be  expected,  a 
similar  degree  of  protection  in  the  inoculated  as  exists 
among  those  who  have  previously  suffered  from  an  attack 
of  typhoid  fever;  consequently  infection,  when  it  does  occur 
in  the  vaccinated,  is  for  the  most  part  mild  in  intensity 
and  anomalous  in  character.  There  is  some  reason  to 
think  that  the  protection  thus  afforded  is  less  marked 
in  those  who  are  past  the  age  of  30  ; l  but  it  is  also  prob- 
able that  individuals  become  progressively  less  susceptible 
as  they  advance  in  life  ;  hence  the  above  advice  applies 
chiefly  to  those  below  that  age.  The  temporary  inconveni- 
ence 5  caused  by  the  injections  cannot  be  held  to  constitute 

1  Crombie,  Lancet,  1902,  ii.  426. 

2  Occasionally  the   symptoms  produced  by  the  original   vaccine 
were  severe  and  even  alarming,  though  no  fatal  results  are  recorded. 
Thus,  Lindsay  (Lancet,  1905,  ii.  827)  saw  a  case  in  which  an  acute 
illness  ensued,  lasting  fourteen  days  ;  and  we  have  seen  a  similar 
case,  in  which  there  was  very  high  fever  (103CV-104°  F.)  for  several 
days,  with  headache,  sleeplessness,  and  distension  of  the  abdomen, 
following  the  second   of    two    injections   which   were   given  at  an 
interval  of  seven  days. 


252       SERUMS,    VACCINES,    AND    TOXINS 

a  sufficient  disadvantage  to  counterbalance  the  protection 
gained. 

We  repeat  that  those  who  are  actually  in  the  midst  of 
an  epidemic  of  enteric  fever  should  not  be  inoculated  with 
an  ordinary  vaccine,  owing  to  the  increased  liability  to 
contract  the  disease  which  at  first  ensues  as  a  result  of  the 
treatment,  but  that  if  a  reliable  "  sensitized "  vaccine  is 
available  we  should  advocate  its  use,  as  a  fair  degree  of 
immunity  is  thereby  secured  practically  immediately. 

VACCINE  TREATMENT 

Petrushky  *  made  experiments  with  a  preparation 
which  he  called  typhdin,  consisting  of  dead  bacilli.  He 
reported  good  results  in  cases  of  uncomplicated  enteric 
fever,  if  the  remedy  were  given  early  in  the  course  of  the 
illness.  It  is  not  suitable  for  patients  in  whom  the  disea.se  is 
advanced  and  in  whom  there  is  already  a  tendency  to  heart- 
failure  or  general  intoxication.  Small,  gradually  increasing 
doses  are  given,  and  the  first  injections  are  accompanied  by 
some  antityphoid  serum,  to  prevent  ill  effects. 

Semple 2  also  reports  favourably  on  the  effects  of 
vaccine  treatment  in  this  disease.  He  used  doses  of  15—30 
millions  of  bacilli  daily  for  four  to  six  days,  and  controlled 
the  results  by  opsonic  estimations.  He  recommends  the  em- 
ployment of  cultures  derived  from  the  individual  patient. 

Pescarolo  and  Quadrone  3  have  used  a  vaccine  of  living 
typhoid  bacilli  upon  patients  suffering  from  the  disease, 
and  noted  good  results — fall  of  temperature  and  rapid 
recovery.  They  made  use  of  agar-cultures  attenuated  by 
heating  to  45°-50°  C.  The  inoculation  is  followed  by  shiver- 
ing and  rise  of  temperature,  while  some  redness  and  swell- 
ing may  appear  at  the  site  of  injection. 

Larger  doses  have  been  used  by  later  workers.  Thus 
Smallman 4  at  Quetta  gave  doses  of  300  to  350  millions 

i  Deut.  med.  Woch.,  1902,  p.  212.        *  lancet,  1909,  i.  1668. 

3  Centralbl.f.  inn.  Med.,  1908,  Xo.  40,  p.  989. 

4  Journ.  Royal  Army  Med.  Corps,  1909,  xii.  136. 

• 


VACCINES    IN   ENTERIC   FEVER          253 

every  third  day  ;  he  reports  a  series  of  36  cases  with  3 
deaths  and  110  relapses.  Callison,1  who  has  .  collected 
extensive  statistics  on  the  subject,  himself  uses  doses 
of  300  millions  to  start  with,  increasing  by  100  millions 
each  successive  dose  at  intervals  of  three  or  four  days.  He 
treated  38  cases  with  a  mortality  of  5  per  cent,  and  a 
relapse-rate  of  1  per  cent.  Among  423  collected  cases  the 
mortality  worked  out  at  5 '4  per  cent.,  and  the  relapse- 
rate  at  6-5  per  cent.  If  Osier's  estimate  of  the  general 
mortality  of  typhoid  fever  at  5-12  per  cent,  in  private 
and  7-12  per  cent,  in  hospital  cases  is  correct,  these 
figures  point  to  some  degree  of  benefit,  but  they  are  not 
large  enough  to  be  very  impressive.  Hollis2  found  some 
apparent  clinical  improvement  as  the  result  of  vaccines, 
but  believed  that  relapse  is  more  frequent — a  curious 
result  of  a  method  devoted  to  increasing  the  patient's 
resistance.  Anders3  states  that  vaccine  treatment  is 
dangerous  in  severe  cases. 

Gauchery4  has  collected  2,294  cases  in  which  vaccines 
were  used  in  enteric  fever,  and  adds  25  of  his  own.  He 
finds  that  25  per  cent,  of  all  cases  respond  rapidly  to  the 
treatment ;  symptoms  quickly  ameliorate,  but  the  tempera- 
ture is  less  influenced,  and  an  outburst  of  roseolar  spots  may 
occur.  In  50  per  cent,  some  benefit  appears  to  result,  but  of 
a  less  striking  nature  ;  while  25  per  cent,  do  not  respond 
in  any  way.  Taking  all  the  cases  together,  the  mortality 
is  reduced  from  9-9  to  5-7  per  cent.  Perforation  of  the 
intestine  is  rare  in  cases  treated  with  vaccines,  but  there  is 
no  marked  diminution  in  liability  to  haemorrhage  or  in  the 
number  of  relapses. 

Mac  Arthur 5  reported   a  series  of  63  cases  of  typhoid 

1  Ned.  Record,  1911,  p.  1129;  Amer.  Journ.  Med.  Science,  1912, 
clxiv.  350.  *  Med.  Record,  1910,  Ixxvii.  6*2. 

8  Ibid.,  1910,  Ixxviii.  1160. 

4  These  de  Paris.  1914  (abstr.  in  Journ.  de  Physiol.  ct  de  Path. 
Gen..  l!)li,  xvi.  757). 

•'Brit.  Med.  Joicrn.,  1914,  ii.  175. 


254       SERUMS,   VACCINES,    AND   TOXINS 

fever  treated  with  a  vaccine  prepared  from  the  B.  typhosus, 
which  had  been  isolated  in  58  cases  from  the  patient's 
blood,  and  in  3  cases  from  the  patient's  f:eces.  With  these 
autogenous  vaccines  there  were  2  deaths  (3-1  per  cent.). 
The  remaining  cases  were  treated  with  a  stock  vaccine. 
The  initial  dose  varied  from  150-300  millions,  and  subse- 
quently increasing  doses  were  injected  at  intervals  of  two 
or  three  days.  The  disease  was  definitely  rendered  milder, 
and  symptoms  other  than  pyrexia  were  absent. 

Vaccines  have  been  recommended  for  the  treatment  of 
typhoid  "  carriers  " — those  who  continue  after  an  attack 
of  the  disease  to  harbour  virulent  bacilli  in  some  part  of 
the  alimentary  system,  usually  the  gall-bladder.  The  results 
obtained,  so  far  as  published  reports  go,  are  not  specially 
encouraging,  but  the  treatment  should  be  given  a  trial  in 
all  persistent  cases. 

ANTISTREPTOCOCCIC    SERUM 

Many  of  the  complications  of  enteric  fever  are  due  to 
secondary  invasion  by  pyogenic  and  other  organisms.  In 
this  belief  Clarke  J  has  tried  the  effect  of  antistreptococcic 
serum  in  purulent  periostitis  occurring  in  enterica.  He 
states  that  the  use  of  this  remedy  was  followed  by  a 
critical  fall  of  temperature  and  a  rapid  cessation  of  the 
suppuration. 

PARATYPHOID    INFECTIONS 

Cases  also  occur,  identical  clinically  with  those  of  enteric 
fever,  but  differing  in  their  etiology,  being  due  to  one  or 
other  of  the  so-called  "paratyphoid"  bacilli  (B.  enteritidis 
of  Gartner  ;  B.  paratyphosus  of  Schottmiiller,  types  a  and 
/3 ;  or  B.  paratyphosus  of  Bryon  and  Keyser).  In  such 
cases  the  organism  can  usually  be  isolated  by  establish- 
ing cultivations  in  suitable  media  from  blood  (5-10  c.c.) 
collected  in  a  sterile  syringe  from  a  vein  in  the  arm. 
The  most  convenient  guide  to  diagnosis  in  those  who 
have  not  received  prophylactic  injections  of  antityphoid 
1  Lancet,  1899,  i.  230. 


ANTIPARATYPHOID   VACCINATION       &>5 

vaccine  is,  however,  the  agglutination  reaction,  for  B. 
tyj)hosus  is  rarely  clumped  by  the  serum  of  these  patients 
in  any  higher  dilution  than  1 : 20  (the  clumping  then 
being  due  to  the  presence  of  gronp-agglutinins),  whilst 
the  organism  responsible  for  the  infection  is  clumped 
in  dilutions  of  1  :  100  and  1  :  200,  and  even  higher. 

In  cases  which  clinically  resemble  enteric  fever,  but  fail 
to  give  a  positive  reaction  to  Widal's  test,  the  agglutinating 
effect  of  the  serum  should  be  tried  on  both  the  varieties 
of  paratyphoid  bacilli  (a  and  /3),  if  these  are  available, 
and  also  on  B.  enteritidis  of  Gartner. 

Franchetti l  has  prepared  an  antitoxic  serum  in  rabbits 
by  injecting  broth -cultures  of  B.  paratyphosus-j3.  The 
serum  agglutinates  this  organism,  but  has  not  been  used 
as  a  remedy  in  human  disease. 

Antiparatyphoid  inoculation. — Castellani,2  in  view 

of  the  frequent  occurrence  of  paratyphoid  infections  in  the 
tropics,  advocated  prophylactic  inoculation  with  "mixed" 
vaccines  (containing  the  various  bacilli  in  the  following 
proportions  —  typhoid  500  millions,  paratyphoid  a  250 
millions,  and  paratyphoid  /3  250  millions  per  cubic  centi- 
metre) in  doses  of  0'6  c.c.,  followed  by  1-2  c.c.  seven  days 
later,  and,  if  possible,  by  a  third  dose  of  1'2  c.c.  a  fortnight 
from  the  first.  No  statistics  are  available  in  proof  of 
the  value  of  this  method,  but,  judging  from  the  results  of 
antityphoid  inoculation,  antiparatyphoid  vaccine  should 
be  equally  efficacious.  Broughton-Alcock  3  has  used  para- 
typhoid vaccines,  both  "  killed  "  and  "  living  sensitized," 
and  we  gather  that  he  has  a  preference  fur  the  use  of  the 
latter. 

CONCLUSIONS 

1.  The  bactericidal  serum  on  the  market,  called  "anti- 
typhoid," is  generally  unsatisfactory  in  its  effects  in  cases  of 

1  Zeitschr.f.  Hyg.,  1908,  Ix.  128. 

2  Ceylon  Med.  Septs.,  1904-5. 

3  Brit.  Med.  Jonrn.,  1914,  ii.  743. 


256       SERUMS,   VACCINES,    AND   TOXINS 

enteric  fever — indeed,  it  is  doubtful  whether  it  can  be  said 
to  have  any  influence  at  all  on  the  course  of  the  disease. 

2.  Good  results  are  reported  with  Chantemesse's  anti- 
toxic serum,  but  there  is  not   yet   sufficient  material   on 
which  to  form  an  authoritative  judgment  as  to  its  value. 

3.  Treatment    by  vaccines  is   even  yet  in  the  experi- 
mental stage,  and  no  dogmatic  opinion  can  be  expressed  as 
to  its  value. 

4.  The    same    criticism    applies    to    Jez's    antityphoid 
extract. 

5.  Wright's  antityphoid  inoculation  constitutes  a  valu- 
able measure  of  protection.      It  is  not  a  certain  means  of 
preventing  an  attack  of  enteric  fever,  but  it  reduces  the 
liability  to  this   occurrence  ;  while,  if  the  disease  does  occur 
in  an  "inoculated"  person,  it  is  generally  milder  than  in 
one  not  so  protected.     It  seems  advisable  for  young  persons 
who  are  going  to  countries  where  enteric  fever  is  rife  to 
undergo  prophylactic  inoculation.     There  is  no  danger  in 
the  procedure,  although  it  may  entail   twenty-four  hours' 
discomfort. 

6.  Antiparatyphoid     inoculation     promises    to     yield 
equally    good   results,    although    at    present    the    subject 
must   be   regarded   as   sub  judice. 

7.  The  Widal  test  (agglutination)  for  enteric  fever  is  a 
useful  means  of  clinical  diagnosis.     It  is  not  infallible,  but 
the    margin    of   error  is  small — perhaps    5  per  cent.     An 
agglutination  in  a  dilution  of  not  less  than  1  :  50  should 
be  obtained  before  the  result  is  called  positive. 


CHAPTER   XIV 

DYSENTERY  AND  OTHER  BACILLARY  INFECTIONS 

DYSENTERY 

APART  from  affections  caused  by  the  Entamceba  dysenteries 
(E.  histolytica),1  the  name  dysentery  is  applied  to  cases  of 
ulceration  of  the  colon  caused  by  a  group  of  nearly  allied 
organisms  which  share  the  title  of  Bacillus  dysenteric. 
The  exact  relationship  of  the  members  of  this  group  is 
as  yet  uncertain.  Varieties  are  distinguished  by  the 
names  of  their  discoverers,  as  the  Shiga  bacillus,  Flexner's 
bacillus,  etc. 

Mile.  Boito 3  concludes  from  a  study  of  agglutination 
experiments  carried  out  with  the  various  organisms  that 
they  fall  into  two  groups — (1)  that  including  the  bacilli  of 
Shiga,  of  Kriise,  of  Flexner  (at  N"ew  Haven),  and  others, 
which  are  agglutinated  in  dilutions  of  1  :  400 ;  (2)  that 
including  the  bacilli  found  by  Flexner  at  Manilla,  by 
Hiss  and  Russell,  by  Kviise  (asylums),  and  by  some  others, 
which  have  less  agglutinative  tendency.  The  question  of 
the  identity  or  diversity  of  the  several  organisms  must  be 
left  at  present  unsettled. 

Toxins. — Martin  3  found  that  by  growing  Shiga's  bacil- 

1  Salvarsan  has  been  given  in  tropical  dysentery,  with  good  results, 
by  Matsuura  (Abstr.  in  Zeit.f.  Immunitdtsforsch.,  1910,  p.  1020),  who 
used  doses  of  0-35  grin.,  and  by  "Wadhams  and  Hill  (Journ.  Amer. 
Med.  Assoc.,  1913,  Ixi.  385). 

2  Gaz.  des  Hop.,  1903,  No.  97,  p.  781,  and  No.  80,  p.  809.     A  full 
bibliography  of  the    subject  is  here  given.     Cf.   Gay  and   Duval, 

Univ.  offenn.  Med.  Bull.,  July -Aug.,  1903,  p.  177. 

3  Thirty-first  Ann.  Rept.  of  L.G.B.,  1901-2;  Supplement  contain- 
ing the  Report  of  the  Medical  Officer,  1903,  pp.  398,  402,     Cf.  Kraus 
and  Doerr,  "  Das  Dysenterie-toxin,"  Jena,  1907. 

R  257 


258       SERUMS,    VACCINES,    AND    TOXINS 

lus  in  peptone-broth  a  soluble  poison  was  produced,  which 
caused  lowering  of  the  temperature  of  animals  into  which 
it  was  injected ;  the  animals  also  suffered  from  diarrhoea 
and  loss  of  weight.  The  most  potent  part  of  the  poison  of 
the  bacillus  is,  however,  intracellular,  the  effect  of  injection 
of  the  dead  bodies  of  the  organisms  being  similar  in  kind 
to  that  of  the  toxins,  but  much  more  pronounced.  The 
toxin  is  apparently  innocuous  if  given  by  the  mouth,  but 
if  injected  into  a  vein  it  causes  the  typical  lesions  of  the 
disease. 

DIAGNOSIS 

Agglutination. — This  bacillus  is  agglutinated  by  the 
serum  of  patients  who  have  recovered  from  the  disease, 
or  of  animals  inoculated  with  cultures.  The  serum  of 
convalescents  was  found  by  Shiga  to  clump  the  bacilli 
in  dilutions  of  1  :  20  or  1  :  30.  This  property  may  remain 
for  a  considerable  time  after  recovery  has  taken  place 
(e.g.  eight  months),  but  the  reaction  does  not  appear  at 
the  beginning  of  the  illness,  so  that  it  is  of  no  importance 
for  clinical  diagnosis.  Use  has  been  made  of  it  for  the 
recognition  of  the  bacillus,  and  for  pi-oving  the  identity 
of  the  varieties  as  described  by  different  authors.  In 
mild  cases  the  reaction  may  never  occur.  Kriise  found 
that  in  cases  of  dysentery  agglutination  might  occur  in 
dilutions  of  1  :  50,  and  even  of  1  :  1,000,  while  normal 
individuals  never  showed  the  phenomenon  in  greater 
dilution  than  1  :  20.  Flexner  found  the  reaction  present 
in  cases  due  to  his  bacillus,  whereas  it  did  not  occur  in 
cases  of  amoebic  dysentery. 

Nicolle  and  Cathoire  l  find  that  agglutination  in  dysen- 
teric infection  is  feeble,  and  that  the  agglutinins  appear  to 
differ  according  to  the  variety  of  bacillus  present.  On  the 
other  hand,  Dopter2  finds  that  the  bacteriolytic  copula 
formed  in  response  to  injections  of  the  bacilli  themselves  is 
the  same  from  all  the  strains. 

J   Compt.  Rend.  Soc.  JJioL,  1906,  No.  30. 
2  Ann.  Inst,  Pasteur,  1905,  xix.  753. 


SERUM  TREATMENT  OF  DYSENTERY     259 

Lucas,  FitzGerald,  and  Schorer1  have  used  the  ag- 
glutination reaction  as  a  means  of  diagnosis  in  infantile 
dysentery. 

SERUM  TREATMENT 

Shiga  inoculated  a  horse  with  his  bacilli,  and  obtained 
from  it  a  serum  which  acted  beneficially  in  cases  of 
dysentery.  He  considered  that  by  its  use  the  mortality 
of  the  disease  was  reduced  by  nearly  50  per  cent.  Kriise 
considers  that  the  serum  prepared  from  his  bacilli  is 
bactericidal,  not  antitoxic.  By  the  use  of  this  remedy 
he  obtained  a  fall  of  mortality  from  10  to  8  per  cent. 
These  figures  do  not  appear  very  striking.  Shiga,2  and 
also  Coyne  and  Auche,3  have  prepared  polyvalent  serums 
by  injection  of  bacilli  belonging  to  all  the  different  varieties. 
These  serums  are  presumably  antibacterial.  Vaillard  and 
Dopter  4  have  prepared  a  serum  by  injection  of  both  toxins 
and  bacilli,  and  record  good  results  (96  cases,  with  1 
death) :  the  dose  used  was  20-100  c.c.,  repeated  as  neces- 
sary. Rosenthal  5  treated  157  cases,  with  7  deaths,  a  mor- 
tality of  4 -5  per  cent,  as  compared  with  10-11  per  cent, 
in  other  German  hospitals ;  the  doses .  used  were  large 
(20-120  c.c.). 

Kraus6  gives  the  following  figures  illustrative  of  the 
value  of  serum  treatment.  In  Galicia  the  mortality  among 
1,420  cases  in  which  it  was  employed  was  9*65,  while 
among  6,914  cases  treated  otherwise  the  deaths  amounted 
to  1'91  per  cent.  Similarly,  in  Bukovina  the  mortality 
was  9'11  per  cent,  among  serum  cases  and  19g2  among 
those  who  received  no  serum.  The  correspondence  of  the 
figures  is  remarkable.  The  doses  used  were  30  to  40  c.c. 
subcutaneously. 

1  Journ.'Amer.  Med.  Assoc.,  Feb.  5,  1910. 

2  Abstr.  in  Centralbl.  f.  Sakt.,  I.  Eef.,  1908,  xli.  742. 

3  Compt.  Send.  Sac.  JBiol.,  1906,  lx.,  No.  26. 

*  Ann.  Inst.  Pasteur,  1906,  xx.  321  ;  1907,  xxi.  241. 

5  Dent.  med.  Woch.,  1904,  xxx.,  No.  19. 

6  Ibid.,  1912,  No.  10. 


260        SERUMS,    VACCINES,    AND    TOXINS 

Ruffer  and  Wildmore1  prepared  a  serum  by  injecting 
horses  first  with  bacterial  cultures  treated  with  pepsin  and 
hydrochloric  acid,  afterwards  with  living  organisms. 

Subsequently  (working  in  Egypt)  they  prepared  different 
forms  of  polyvalent  serum  by  inoculating  horses  subcu- 
taneously  and  intramuscularly  (1)  with  a  mixture  of 
different  strains  (Shiga,  Kriise,  Flexner,  El  Tor),  and  (2) 
separately  with  different  strains  of  the  El  Tor  and  of  the 
Shiga  varieties.  These  various  serums  were  then  employed 
in  the  treatment  of  bacillary  dysentery  in  the  following 
manner  :  They  examined  the  patients'  serum  for  ag- 
glutinating properties  towards  these  different  varieties  of 
dysentery  bacilli,  and,  if  one  or  other  agglutinin  pre- 
dominated, used  the  corresponding  serum  ;  while  for  a 
preliminary  dose,  or  in  case  of  doubt,  they  used  the  former 
kind  of  serum — a  "  shot-gun "  preparation  against  all 
known  organisms  responsible  for  the  disease.  The  doses 
were  40-60  c.c.  in  mild  cases,  80  c.c.  in  severe  cases,  and 
100-120  c.c.  in  desperate  instances.  The  results  were 
encouraging,  improvement  in  the  patient's  general  condition 
usually  ensuing  in  four  to  twelve  hours,  though  the  stools 
often  remained  apparently  uninfluenced  for  some  days.  The 
serum  was  of  no  use  in  amo?bic  cases — an  argument  against 
the  view  still  maintained  by  German  writers  that  the 
arnrebse  are  saprophytes  in  an  intestine  already  injured  by 
the  bacilli  of  dysentery. 

Lesage  2  prepared  a  serum  by  inoculation  with  his  cocco- 
bacillus,  which  reduced  the  mortality  in  the  cases  he  observed 
by  50  per  cent.  Moreul  and  Rioux  3  also  produced  a  serum 
by  means  of  the  variety  of  B.  coli  which  they  considered  to 
be  the  causal  agent  in  the  cases  they  examined ;  they  found 
that  it  was  both  preventive  and  curative. 

Prophylaxis. — Castellani  has  advocated  the  prophy- 
lactic use  of  dysentery  vaccine ;  and  recently  Broughton 

1  Brit.  Med.  Journ.,  1910,  ii.  1519. 

2  Bull,  de  la  Soc.  fie  Biol'f/ie,  1902,  p.  705. 

3  Quoted  by  Mile.  Boiito,~o^.  cit. 


INFANTILE    ENTERITIS  261 

Alcock !  has  employed  for  the  same  purpose  a  sero-vaccine 
in  which  au  inactivated  normal  serum  (human  or  equine)  is 
used  precisely  as  if  it  were  an  immune  serum,  to  treat  the 
bacilli,  and  claims  for  the  process  abolition  of  toxic  effects 
of  the  vaccine  and  the  production  of  a  higher  grade  of 
immunity. 

VACCINE  TREATMENT 

In  cases  of  chronic  dysentery,  rebellious  to  other  treat- 
ment, Forster  -  found  benefit  to  accrue  from  the  use  of  a 
vaccine  of  dead  organisms.  He  used  cultures  of  Shiga's 
bacillus  heated  to  60°-63°  C.  and  suspended  in  salt-solution. 
The  value  of  this  treatment  is  confirmed  by  Stephens  3  and 
by  Newman.4 

Dopter  5  has  shown  that  vaccine  prepared  from  cultures 
of  Shiga's  bacillus  and  treated  with  specific  antiserum 
gives  an  early  and  prolonged  immunity  in  experimental 
animals. 

INFANTILE   ENTERITIS,  OR   SUMMER  DIARRHCEA 

The  Bacillus  dysenterice  has  been  found  in  cases  of  the 
summer  diarrhoea  of  infants,  and  is  considered  by  some 
writers  to  be  the  cause  of  the  disease.6  Morgan7  has 
isolated  a  bacillus,  "No.  1,"  from  some  63  per  cent,  of  the 
cases  which  he  investigated,  and  regards  it  as  the  causal 
agent.  It  is  probable  that  more  than  one  bacterial  agent 
can  give  rise  to  the  morbid  conditions  classed  under  this 
heading.  Kriise  obtained  good  results 'from  serum  treat- 
ment in  cases  of  dysentery  in  children,  reducing  the 

1  Urit.  Med.  Journ.,  1914,  ii.  306. 

2  Ind.  Med.  Gaz.,  1907,  p.  201. 
»  Ibid.,  p.  375., 

4  Lancet,  1908,  i.  1410. 

*  Ann.  Inst.  Pasteur,  1909,  xxiii.  676. 

6  See  Martha  Wollestein,  "  The  Dysentery-Bacillus  in  a  Series  of 
Cases  of  Infantile  Diarrhoea,"  Journ.  of  Med.  Mesearch,  Aug.,  1903, 
p.  11. 

7  Proc.  Hoi/.  Soc.  Med.,  March,  1909. 


262       SERUMS,    VACCINES,    AND    TOXINS 

mortality  from  15  to  5  per  cent.  Gay  l  considered  that  the 
prospect  of  serum  treatment  in  summer  diarrhoea  was  very 
hopeful ;  but  the  reports  of  the  Rockefeller  Institute  on 
the  use  of  antidysenteric  serum  in  this  affection  are  not 

encouraging.2 

COLITIS 

Membranous,  mucous,  and  ulcerative  colitis  are  terms 
employed  to  denote  a  condition  or  group  of  conditions 
which  some  observers  consider  to  be  identical  with  bacillary 
dysentery,  especially  the  cases  which  occur  in  asylums  for 
the  insane.  Sporadic  cases  of  long  standing  have  been 
found  by  Hale  White  and  Eyre  3  to  be  amenable  to  treat- 
ment with  autogenous  vaccines  prepared  from  B.  coli  com- 
munis  variants,  especially  a  coliform  bacillus  which  does 
not  ferment  lactose  present  in  the  intestine  and  faeces 
of  patients,  and  which  Eyre  believes  to  be  causally  associ- 
ated with  the  condition.  Similarly,  Streptococcus  longus  or 
pneumococci  may  sometimes  be  found  in  the  dejecta  of 
the  haemorrhagic  types  of  colitis,  and  in  these  cases  treat- 
ment with  autogenous  vaccines  usually  gives  good  results. 
In  view  of  the  intractable  nature  of  the  conditions,  trial 
of  vaccine  treatment  is  certainly  to  be  recommended  before 
adopting  the  ultimum  refugium — now  so  often  the  first 
thought  of  the  medical  attendant — a  surgical  operation. 

AFFECTIONS   DUE  TO  BACILLUS   COLI   COMMUNIS 

The  Bacillus  coli  communis  is  a  normal  inhabitant  of 
the  human  intestine.  Under  certain  circumstances,  such 
as  constriction  of  the  gut,  injury  to  the  peritoneum,  per- 
foration of  the  intestine,  etc.,  it  is  capable  of  giving  rise  to 
serious  symptoms ;  it  may  also  be  found  in  suppurative 
conditions,  such  as  pyelitis  and  cystitis,  otitis  media,  etc., 
attended  sometimes  by  considerable  elevation  of  tempera- 
ture ;  in  all  of  these  it  acts  as  a  pyogenic  organism. 

1   Univ.  of  Penn.  Ned.  Bull.,  Nov.,  1902. 
-  See  Brit.  Med.  .Town.,  1904,  i.  1653. 
3  Lancet,  1909,  i.  1586. 


B.  coli  alone  may  also  give  rise  to  a  true  septicsernia, 
and  is  frequently  associated  with  Streptococcus  longus  in 
the  causation  of  puerperal  septicaemia,  thus  explaining  the 
occasional  failure  of  antistreptococcic  serum  to  check  the 
course  of  that  infection.  This  bacillus  appears  sometimes 
to  have  some  association  with  Graves's  disease,  since  we 
have  found  in  several  cases  that  the  inoculation  of  small 
doses  of  autogenous  B.  coli  vaccine  has  been  followed  by 
decrease  in  the  objective  signs  of  the  disease,  whilst  a 
large  dose  has  been  promptly  followed  by  increase  in 
the  size  of  the  thyroid  accompanied  by  distressing 
palpitation. 

Toxins. — Carega T  has  isolated  two  toxic  substances 
from  broth-cultures  of  these  bacilli — a  nuclein  and  a 
nucleo-albuinin :  to  the  latter,  no  antibody  is  apparently 
formed  in  injected  animals. 

Attempts  to  prepare  an  antitoxic  or  bactericidal  serum 
against  this  organism  have  not  been  successful  in  the  hands 
of  Albarran  and  Mozer  ;  2  but  antiserums  to  the  Bacillus 
coli  are  still  on  the  market. 

Vaccine  treatment  has  proved  of  great  value.  Thus, 
Wright  3  caused  the  closure  of  a  sinus  left  after  operation 
by  means  of  a  vaccine  of  the  organism  ;  and  this  procedure 
was  also  used  by  Hawkins  and  Corner 4  in  a  case  of  in- 
fection following  laparotomy  for  appendicitis.  Gray  5  has 
used  coli  vaccine  with  success  in  cases  of  pyelitis ;  and 
Hicks 6  reports  favourably  on  its  use  in  the  treatment 
of  the  pyelitis  of  pregnancy.  Good  results  are  reported 
in  two  cases  of  cholecystitis,  the  dose  of  vaccine  being 
100  to  200  millions  of  dead  bacilli.7  We  have  found  the 

1  Centralbl.f.  Bakt.,  1903,  xxxiv.,  No.  4. 

2  Journ.  Amer.  Med.  Assoc.,J&n.  17,  1899. 

*  Trans.  Path.  Soc.  London,  1!)06. 

*  Brit.  Med.  Journ.,  1908,  ii.  782. 
5  Lancet,  1906,  i.  1102. 

«  Jirit.  Med.  Journ.,  1909,  i.  203. 

7  Wright  and  Reid,  ibid.,  1906,  i.  143. 


264       SERUMS,    VACCINES,    AND    TOXINS 

treatment  of  great  value  in  cases  similar  to  the  above ; 
also  in  cystitis,  subdiaphragmatic  abscess,  etc.  The  vaccine 
must  be  prepared  from  the  patient's  own  organism,  for 
in  coli-infections  stock  vaccines  are  useless.  The  initial 
dose  is  usually  2-5  to  5  millions,  repeated  in  from  two  to 
three  days.  Subsequent  doses  are  generally  given  at  in- 
tervals of  about  a  week  in  increasing  quantities  up  to 
a  maximum  of  50  millions.  It  will  often  be  found  that 
after  a  period  of  improvement  the  patient  ceases  to  respond 
to  the  injections  of  vaccine,  and  on  investigation  it  will 
sometimes  be  found  that  the  colon  bacillus  still  infecting 
the  individual  has  varied  slightly  in  its  biological  character  ; 
if  that  is  so  a  fresh  vaccine  prepared  from  this  new  strain 
will  often  complete  the  cure.  At  other  times  recourse  to  a 
sensitized  vaccine  will  have  the  same  effect. 

AFFECTIONS  DUE  TO  BACILLUS  PYOCYANEUS 

The  blue  coloration  of  pus,  particularly  that  so  often 
noted  as  following  extensive  burns,  is  due  to  Bacillus 
pyocyaneus,  called  also  the  "bacillus  of  blue  pus." 

Toxins. — Maclutyre  '  found  that  the  bodies  of  the 
bacilli  contained  an  intracellular  toxin  and  a  haemolysin. 

Antitoxic  senim. — Wassermann  obtained  both  an 
antitoxic  and  a  bactericidal  serum  by  injection  respectively 
of  the  toxins  and  of  the  bacillus  itself  into  animals.  These 
serums  had  both  a  protective  and  a  curative  action  on 
animals. 

We  have  found  vaccine  treatment,  in  doses  of  50  and 
100  millions,  of  value  in  cases  of  osteomyelitis,  shrapnel 
wounds,  and  suppurating  sinus  following  laparotomy  for 
ovarian  tumour. 

An  extract  of  the  bacilli  was  prepared  by  Emmerich  and 
Low  2  by  autolysis,  and  is  called  "  pyocyanase."  It  seems  to 
act  as  a  bactericidal  agent  not  only  on  B.  pyocyaneus  but 
also  upon  other  pathogenic  bacteria.  It  has  been  used  by 

1  Journ.  Amer.  Med.  Assoc.,  April,  1904,  p.  1074. 
-  Zeitfchr.  f.  Hyg.,  1899,  xxxi.  1  ;  1901,  xxxvi.  9. 


YELLOW    FEVER  265 

Hof bauer 1  in  cases  of  vaginal  gonorrhoea,  with  only  transi- 
tory benefit ;  and  by  Escherich  ~  as  a  local  disinfectant  in 
nasal  catarrh  due  to  Micrococcus  catarrhalis,  and  in  cerebro- 
spinal  meningitis.  In  the  former  affection  it  was  very 
successful,  but  in  the  latter  its  value  was  not  definitely 
proved.  It  has  also  been  used  as  a  local  application  to  the 
false  membrane  in  diphtheria  and  in  ulcus  molle.  In  this 
last  the  application  is  a  somewhat  painful  procedure. 

YELLOW   FEVEK 

Etiology. — The  causation  of  yellow  fever  is  at  present 
unsettled.  Sanarelli  3  isolated  a  bacillus  to  which  he  gave 
the  name  of  Bacilhis  icteroides,  and  which  he  believed  to  be 
the  pathogenic  agent.  The  claims  of  this  organism,  how- 
ever, have  not  been  supported  by  other  observers.  Parker, 
Beyer  and  Pothier  *  have  found  a  protozoan  organism  which 
they  named  Myxococcidium  stegomyicv,  and  which  is  possibly 
the  cause  of  the  disease.  This  coccidium  is  found  by  them 
in  the  bodies  of  gnats  which  have  sucked  the  blood  of  patients 
suffering  from  yellow  fever.  It  is  now  practically  proved 
that  the  disease  is  transmitted  by  the  bites  of  the  variety  of 
gnat  called  Stegomyia  fasciata,  and  Findlay  5  suggests  that 
this  insect  is  the  principal  host  of  the  parasite  of  yellow 
fever,  which  only  passes  a  subordinate  stage  of  its  existence 
in  human  beings.  Its  life-cycle  would  thus  be  just  the 
opposite  of  that  of  the  organism  of  malaria,  which  has  man 
for  its  definitive  host.  It  is,  however,  more  than  probable 
that  the  true  cause  of  the  disease  still  remains  to  be 
discovered. 

Toxins  of  B.  icteroides. — Baker6  injected  toxins  de- 
rived from  Bacillus  icteroides  into  patients,  and  found  that 

1  Centralbl.f.  Gynak.,  1908,  No.  6. 
-  Wien.  klin.'Woch.,  1906,  xix.  751. 

3  Ann.  de  VInst.  Pasteur,  1897,  xi.  433. 

4  United  States  Public  Health  and  Marine  Hospital  Service  ( Yelluiv 
Fever  Bulletin,  No.  13),  1903. 

6  Rivista  de  Medicine  Tropical,  1903,  No.  4,  p.  49. 
6  See  Journ.  Amer.  Med.  Assoc.,  April  14,  1900. 


266       SERUMS,   VACCINES,    AND   TOXINS 

they  produced  the  typical  phenomena  of  a  rising  pulse  and 
falling  temperature  (Faget's  pulse  and  temperature),  which 
are  peculiar  to  this  disease. 

Serum  treatment. — Sanarelli  l  prepared  an  "  ami- 
auiarillic  "  serum  2  by  inoculating  a  horse  with  his  bacilli, 
and  used  it  in  cases  of  the  disease,  apparently  with  good 
effect.  He  reports  that  the  injection  is  followed  by  a 
febrile  reaction,  which  in  turn  is  .succeeded  by  remission 
of  the  symptoms.  Among  8  cases  in  which  he  used  small 
doses  of  the  serum  there  were  2  deaths  and  6  recoveries  ; 
while  of  14  severe  cases  in  which  larger  quantities  were 
employed,  10  recovered. 

Prophylactic  injections  of  the  serum  were  used  in  the 
case  of  an  outbreak  which  had  occurred  in  a  jail,  and  after 
the  injections  were  carried  out  no  more  cases  of  the  disease 
were  met  with. 

Agramonte3  has  tried  the  serum  of  convalescent*  in 
yellow  fever,  and  thinks  that  "good  effects  are  produced. 
Other  observers  have  not  been  equally  successful. 

Vaccination  with  the  Bacillus  icteroides  in  accordance 
with  Haffkine's  method  is  capable  of  protecting  animals 
against  infection  with  this  organism. 

WHOOPING-COUGH      . 

Various  organisms  have  been  claimed  by  different 
observers  as  the  causal  agent  of  whooping-cough,  but, 
despite  the  effect  of  certain  so-called  specific  serums 
referred  to  below,  the  bacillus  described  by  Jochmann, 
Bordet,  and  others  possesses  the  strongest  claims  to  recog- 
nition. The  Bacillus  pertussis  is  a  minute  slender  rod 
belonging  to  the  influenza  group  of  hjeinophilic  bacteria  ; 
that  is  to  say,  it  does  not  retain  the  stain  by  Gram's 

1  Ann.  de  Vlnst.  Pasteur,  1898.  xii.  348. 

-  Amarillic,  from  the  Spanish  name  of  the  disease,  "fiebre 
amarilla." 

3  Quoted  by  Fitzpatrick,  Journ.  of  the  American  Med.  Atsoc., 
April  14,  1900,  p.  905. 


WHOOPING-COUGH  267 

method,  will  only  develop  in  artificial  media  containing 
blood  or  serum,  and  only  at  the  temperature  of  the  body. 

Serum  treatment. — Elena  Manicatide  l  obtained  pure 
cultures  of  a  peculiar  bacillus  from  the  sputum  of  patients, 
and  with  them  inoculated  a  sheep  and  a  horse.  The 
serum  obtained  from  these  animals  appeared  to  exert  a 
favourable  influence  on  the  disease,  the  number  of  attacks 
diminishing  under  the  treatment,  and  convalescence  being 
more  rapid. 

Leuriaux2  found  in  cases  of  whooping-cough  a  short, 
thick  bacillus,  almost  as  broad  as  it  was  long.  It  was 
motile  and  aerobic,  growing  well  on  gelatin  and  other 
laboratory  media  ;  and  it  retained  the  colour  when  treated 
by  Gram's  method.  He  inoculated  rabbits  with  this  organ- 
ism, which  produced  death  if  it  was  given  intravenously, 
while  if  it  was  given  subcutaneously  a  local  abscess  was 
formed.  Convulsive  movements  of  the  diaphragm  were 
seen  in  some  instances,  which  may  be  analogous  to  the 
convulsive  seizures  of  pertussis.  Leuriaux  inoculated  a 
horse  with  the  organisms,  and  treated  cases  of  whooping- 
cough  with  its  serum.  He  considers  that  the  effects  pro- 
duced were  good,  cure  being  brought  about  in  six  to  eight 
days.  He  employed  doses  of  5  c.c.,  and  advises  the  early 
administration  of  the  remedy. 

It  is  noteworthy  that  these  two  observers  agree  in 
finding  a  specific  bacillus  and  in  obtaining  good  results  by 
serum  treatment.  It  is  impossible  to  know  whether  the 
organism  isolated  was  the  same  in  both  cases.  Much  further 
experimental  evidence  is  necessary,  both  as  to  the  specificity 
of  the  bacillus  and  as  to  the  efficacy  of  the  serum,  before 
we  can  conclude  that  a  true  remedy  has  been  discovered 
for  this  malady.  The  course  of  the  disease  is  so  irregular, 
and  the  difficulty  of  judging  of  the  value  of  any  treatment  is 
so  great,  that  a  considerable  degree  of  scepticism  is  justifiable 
in  the  case  of  any  new  "  cure  "  which  is  brought  forward. 

1  Spitalul,  1902,  No.  6  (abstr.  Centralbl.  f.  wn.  Med.,  1903,  p.  199). 

2  La  Semaine  Med.,  1902,  p.  233. 


268       SERUMS,    VACCINES,    AND    TOXINS 

Silvestri1  used  injections  of  the  serum   or  <•>,,,,, -al- • 
(15-20  c.c.)  in  7  cases  of  whooping-cough,  all  of  which  were 
apparently  reliev«  tl. 

Non-specific  treatment. — Indica-  and  other  observers 
speak  favourably  of  the  use  of  diphtheria!  antitoxin  in 
whooping-cough.  Indica  treated  8  cases  with  this  serum, 
which  he  considers  to  act  by  stimulating  leucocytosis  and 
increasing  the  resistance  of  the  patient. 

Porchi3  thinks  that  vaccination  (vaccinia)  is  both  pro- 
phylactic and  curative. 

Vaccine  treatment. —  Some  writers  record  their 
experiences  with  vaccines  of  the  Bordet-Gengou  bacilli. 
Thus,  Bamberger4  gave  doses  of  20  millions  of  these 
organisms  in  6  cases,  and  thought  that  the  severity  of  the 
symptoms  was  reduced  but  the  duration  of  the  illness  was 
not  lessened.  Scott5  gave  doses  of  40  millions  even  to 
infants,  and  arrived  at  very  similar  conclusions  as  to  the 
effects  of  the  treatment;  and  Graham6  with  these  doses 
noted  apparent  improvement  in  17  of  24  cases.  Ladd,7 
however,  found  the  procedure  useless. 

Nicolle  and  Conor8  used  a  vaccine  of  living  organisms 
(Bordet-Gengou),  administering  1  to  •">  minims  of  a  sus- 
pension containing  400  millions  of  the  organisms  hi  1  c  c. 
saline  solution.  They  do  not  seem  to  have  been  favourably 
impressed  with  the  results  attained. 

BOTULISM 

The  word  "  botulism,"  originally  applied  to  any  form  of 
"  sausage  poisoning,"  is  now  confined  to  affections  produced 

1  Gaz.  degli  Ospedali,  1903,  No.  114. 

2  Ibid.,  1900,  xxi.  968. 

3  Ibid.,  1903,  Xo.  114. 

4  Amer.Jotirn.  Dis.  of  Children,  1913,  v.  33. 
3  -V.T.  M>,L  J.n,,,,.  .Jan.  25.  1913. 

6  Med.  Record,  1911,  Ixxx.  402. 

7  Arelt.  of  Pediatr.,  1912. 

8  Compt.  Rend.  Acad.  Sci.,  1913,  clvi.  1819. 


BOTULISM  269 

by  eating  meat  contaminated  with  a  particular  micro-organ- 
ism, the  Bacillus  botulinus,  discovered  by  van  Ermengem. 

By  growing  the  bacilli  in  broth  and  filtering  the  cultures, 
Kempner1  obtained  a  toxin  which,  when  injected  into 
goats,  produced  an  antitoxic  serum .  This  was  found  capable 
of  protecting  rabbits  against  many  times  the  lethal  dose  of 
the  toxin,  and  also  of  exerting  a  curative  effect  if  given 
some  hours  after  the  poison.  ISTo  records  of  the  use  of  this 
serum  in  human  beings  are  available. 

The  toxin  gives  rise  in  the  cells  of  the  spinal  cord  to 
changes  of  a  degenerative  nature,  similar  to  those  found  in 
fatal  cases  of  the  disease. 

1  Zeitschr.f.  Hyrj.,  1897,  Bd.  xxvi. 


CHAPTER  XV 
TUBERCULOSIS 

ETIOLOGY 

Causal  bacillus  and  toxins. — The  Bacillus  tuberculosis 
was  discovered  by  Koch  in  1882.  By  growing  the  bacteria 
in  glycerin-bouillon  some  of  the  toxins  may  be  obtained, 
but  the  bodies  of  the  bacilli  are  themselves  toxic,  acting 
as  distinct  irritants  even  when  they  are  dead.  The  toxins 
of  the  tubercle  bacillus  are  not  well  understood.  A  pecu- 
liar acid  formed  by  it  has  been  credited  with  the  power 
of  producing  the  characteristic  degeneration  of  the  tissues 
called  "caseation."  Another  substance  gives  rise  to  fever  ; 
and  certain  volatile  products  are  said  to  have  a  convulsant 
effect.  The  bacilli  may  cause  death  in  two  ways — either 
by  rapid  multiplication  and  formation  of  toxins,  as  in 
acute  miliary  tuberculosis;  or  by  producing  gradual  destruc- 
tion of  some  organ  necessary  to  life,  such  as  the  kidney 
or  the  lung.  In  these  latter  cases  there  is  often  a  super- 
added  infection  by  pyogenic  organisms,  staphylococci,  etc., 
to  the  toxic  effects  of  which  the  profuse  sweats  so  character- 
istic of  advanced  tuberculosis  are  principally  due,  and  very 
possibly  also  much  of  the  ulcerative  destruction  of  tissue 
met  with  in  cavities  in  the  lungs  as  well  as  in  superficial 
lesions. 

The  question  of  the  identity  or  difference  of  human 
and  bovine  bacilli  is  still  undecided.  Professor  Koch  held 
that  the  organisms  were  distinct,  and  that  bovine  tubercle 
could  not  be  conveyed  to  man,  nor  human  tubercle  to  cattle. 
The  general  opinion  at  the  present  time  appears  to  be  that 
there  is  no  such  absolute  distinction  between  them,  although 

270 


TUBERCULIN  271 

the  difficulty  of  infecting  bovine  animals  with  human  bacilli 
is  admitted  to  be  very  great.  Birds  suffer  from  a  special 
form  of  tubercle,  which  appears  to  be  caused  by  a  distinct, 
though  nearly  allied,  organism,  and  cold-blooded  animals 
(snake,  tortoise)  also  suffer  from  an  infection  produced  by 
an  acid-fast  bacillus.  Use  has  been  made  of  the  different 
varieties  of  the  B.  tuberculosis  for  the  purpose  of  immunizing 
animals,  inoculation  with  •  bacteria  of  the  kind  special  to 
another  animal  not  producing  tuberculosis,  but  rendering 
the  animal  inoculated  immune  against  that  form  of  the 
disease  from  which  it  is  liable  to  suffer. 

TUBERCULIN 

Artificial    preparation    of    the    toxins    of    the 

tubercle  bacillus. — Koch  found  that  by  growing  the 
bacilli  from  six  weeks  to  two  months  in  flasks  containing 
slightly  alkaline  veal-broth,  to  which  a  percentage  of  pep- 
tone and  of  glycerin  had  been  added,  and  freely  supplying 
the  cultures  with  oxygen  throughout,  it  was  possible  to 
obtain  a  fluid  containing  some,  at  any  rate,  of  the  toxins 
produced  by  the  organisms.  By  passing  this  through  a  por- 
celain filter  the  bodies  of  the  bacteria  were  removed,  and 
a  solution  of  the  poisons  remained.  This  was  concentrated 
by  evaporation  to  one-tenth  of  its  bulk,  and  to  the  fluid 
thus  obtained  the  name  of  tuberculin  (T.  or  O.T.,  Old  or 
Original  Tuberculin ;  sometimes  A.T.,  Alt  Tuberculin)  was 
given.  It  was  hoped  that  this  preparation  would  exert  a 
curative  effect  on  tubercular  disease  (phthisis),  and  the 
discoveiy  was  announced  to  the  world  as  a  "  cure  for 
consumption."  Great  hopes  were  thus  raised,  only  to  be 
dashed  to  the  ground  when  further  experience  was  gained 
as  to  the  limitations  of  the  method  and  the  inconstancy  of 
the  good  results  produced.  The  reaction  which  ensued  as 
the  result  of  this  disappointment  undoubtedly  went  too 
far  in  the  opposite  direction,  and  the  limited,  but  really 
valuable,  properties  of  tuberculin  as  an  aid  to  treatment 
were  overlooked  or  denied. 


272       SERUMS,    VACCINES,    AND    TOXINS 

Composition  Of  tuberculin.  —  Tuberculin,  as  thus 
prepared,  is  a  somewhat  thick  fluid,  of  dark-yellow  colour. 
It  is  practically  a  solution  in  glycerin  of  the  substances, 
toxic  and  other,  formed  by  the  bacillus  during  its  growth  in 
a  fluid  medium,  since  the  glycerin  added  to  the  original 
culture-medium  does  not  evaporate  on  heating,  while  the 
water  is  driven  off.  A  careful  analysis  of  tuberculin,  as 
originally  prepared  by  Koch,  was  made  by  W.  Hunter,1  as 
the  result  of  which  he  came  to  the  conclusion  that  it  was  a 
very  complex  substance.  He  separated  from  it  (besides 
glycerin,  etc.)  alkaloids,  albumoses,  and  extractives.  He 
considered  that  the  material  which  produces  the  febrile 
reaction  was  of  the  last  class,  and,  as  these  matters  are 
separable  by  dialysis,  he  hoped  to  produce  a  tuberculin  free 
from  the  objectionable  features  of  Koch's  preparation.  The 
remedial  substance  is,  in  his  view,  probably  an  albumose,  as 
is  also  that  producing  the  inflammatory  reaction  around  the 
foci  of  tuberculosis.  There  are  thus  at  least  three  active 
principles  present  in  tuberculin. 

Koch,  as  the  result  of  independent  analysis,  agreed  in 
considering  that  the  most  important  material  was  of  the 
nature  of  an  albumose,  but  he  was  doubtful  as  to  its 
exact  chemical  nature,  owing  to  its  power  of  resisting 
high  temperatures — a  peculiarity  which  Hunter  also  had 
noted. 

Koch's  later  tuberculins. — In  addition  to  the  above 
tuberculin,  Koch  ~  subsequently  introduced  other  remedial 
preparations  of  tubercle  bacilli.  (1)  Instead  of  the  toxin 
produced  by  growth  of  the  bacilli  in  a  fluid  medium,  he  made 
use  of  extracts  of  the  organisms  themselves.  He  took  highly 
virulent  cultures  of  tubercle  bacilli,  dried  them  in  vacuo, 
and  triturated  them  in  a  mortar.  The  resulting  powder 
was  treated  with  sterile  distilled  water,  and  submitted  to 
centrifugalization.  The  supernatant  clear,  but  opalescent, 
fluid  was  then  removed  from  the  debris,  and  20  per  cent. 

1  Brit.  Med.  Joitrn.,  1891,  ii.  169. 
1  Deut.  med.  Woch.,  1897,  p.  209. 


TUBERCULIN  273 

of  glycerin  added  as  a  preservative.  To  it  Koch  gave 
the  name  of  Tuberkulin-O  (T.O.),  or  "Oberer  (Upper) 
Tuberkulin."  This  corresponds  in  composition  and  action 
with  the  original  tuberculin,  T.  (2)  The  solid  residue 
thus  freed  from  soluble  toxins  was  then  dried,  and 
the  process  of  extraction  by  triturating  with  20  per 
cent,  glycerin-solution  and  then  centrifugalizing  was  re- 
peated several  times,  the  fluid  used  each  time  being  pre- 
served, and  the  whole  finally  mixed  together.  This  mixture 
constituted  the  New  or  Residual  Tuberculin  (T.  ruckstand, 
T.R.).  Koch  claimed  that  specially  valuable  properties 
reside  in  this  last  preparation,  gradually  increasing  doses 
injected  into  animals  producing  immunity  to  tuberculosis, 
and  also  to  the  action  of  the  other  forms  of  tuberculin. 
(3)  A  third  modification  (T.A.,  I'uberculin  alkalinum)  is 
obtained  by  extracting  dried  tubercle  bacilli  with  deci- 
normal  soda-solution,  and  filtering  the  fluid.  Tuberculin-O 
and  Tuberculin-A  produce  effects  very  similar  to  those  of 
the  Old  Tuberculin  (T.).  (4)  A  fourth  modification,  known 
as  " New-Tuberculin  B.E."  (bacillus  emulsion),  is  merely  a 
suspension  of  5  mg.  of  powdered  tubercle  bacilli  in  1  c.c.  of 
50  per  cent,  solution  of  glycerin,  and  is  the  equivalent  of 
an  ordinary  bacterial  vaccine. 

All  the  preparations  previously  mentioned  are  manu- 
factured from  B.  tuberculosis  of  the  human  type.  Pre- 
cisely similar  preparations  are  made  from  B.  tuberculosis 
of  the  bovine  type,  and  these  are  indicated  by  prefixing 
the  letter  P.  (Perlsucht)  to  the  letter  or  combination  of 
letters  which  stand  for  those  prepared  from  human 
tubercle  bacilli. 

Action  Of  tuberculin. — It  is  found  that  if  a  minute 
quantity  of  the  original  preparation  (old  tuberculin)  is 
injected  hypodermically  into  a  patient  or  animal  suffering 
from  tuberculosis,  very  definite  symptoms  are  produced. 
There  is  a  rise  of  temperature  of  varying  intensity,  from 
one  to  three  or  more  degrees  Fahrenheit,  accompanied  by 
a  feeling  of  illness  and  sometimes  by  nausea  or  even 


274       SERUMS,    VACCINES,    AND    TOXINS 

vomiting.  At  the  seat  of  any  localized  focus  of  tuber- 
culosis which  is  open  to  observation  there  occurs  a  more 
or  less  vigorous  reaction,  with  heat  and  redness ;  and  often, 
if  this  is  severe,  there  is  a  casting-off  of  necrosed  pieces  of 
tissue. 

The  mode  of  production  of  the  fever,  in  the  case  alike  of 
the  old  and  of  the  new  tuberculin,  is  riot  well  understood. 
It  cannot  be  due  to  the  existence  in  the  tuberculin  of 
a  direct  thermogenic  substance,  as  in  that  case  normal 
individuals  would  be  affected  in  the  same  way  as  the  tuber- 
culous. It  has  been  suggested  that  in  the  case  of  the  old 
tuberculin  the  fever  is  the  result  of  the  local  inflammation 
excited  around  the  lesions,  but  this  is  doubtful  in  view  of 
the  similar  action  of  the  new  preparation,  which  is  not 
followed  by  any  such  local  effects.  We  are  driven  to  suppose 
that  there  is  an  interaction  between  two  substances,  one 
contained  in  the  tuberculin  and  the  other  present  in  the 
body  of  the  tuberculous  individual,  the  result  of  which  is 
the  formation  of  some  pyogenic  substance  as  yet  unknown.1 
The  explanation  put  forward  by  Ehrlich  is  as  follows  : 
The  normal  cells  of  the  body  are  not  affected  by  this  sub- 
stance, nor  are  those  which  form  the  actual  tubercular 
tissue.  Probably  the  latter  are  habituated  to  the  poison, 
as  they  are  in  close  relation  with  the  bacilli  which  are  con- 
stantly giving  rise  to  its  formation.  There  is,  however,  a 
zone  of  cells  at  a  certain  distance  from  the  centre  of  infec- 
tion which  have  been  only  so  far  affected  by  the  poisons  of 
the  bacillus  as  to  be  rendered  unusually  susceptible  to  their 
influence.  When  an  injection  of  tuberculin  is  adminis- 
tered, an  additional  quantity  of  poison  is  brought  into 
contact  with  these  cells,  and  they  are  thus  stimulated  to 
react.  The  reaction  takes  the  form  of  inflammation — the 
process  by  which  dead  or  dying  tissues  are  cast  oft'  from  the 
body,  as  is  seen  in  the  separation  of  a  sequestrum  or  a 

1  Krehl  and  Matthes  found  that  albumoses  derived  from  many 
different  souices  produced  effects  precisely  similar  to  those  of  tuber- 
culin. (Arch.f.  expcr.  Palh.  tt.  Phannali.,  1893,  xxxvi.  437.) 


ACTION    OF    TUBERCULIN  275 

slough.  Hence  the  necrotic  tubercular  tissues  tend  to  be 
cast  off  by  the  action  of  the  tuberculin,  and  a  more  or 
less  healthy  granulating  surface  is  left  in  favourable 
cases. 

The  anatomical  effects  produced  in  a  tuberculous  subject 
by  an  injection  of  tuberculin  may  be  best  seen  in  an  infected 
guineapig  which  has  been  killed  by  the  injection  of  a  large 
dose  of  this  substance.  A  zone  of  hypersemia  may  be  seen 
surrounding  each  of  the  grey  nodules  characteristic  of  the 
disease,  which  occur  throughout  all  the  internal  organs. 
Healthy  guineapigs  can  tolerate  even  large  doses  of  tuber- 
culin without  manifesting  any  symptoms ;  tuberculous 
animals  are  killed  by  a  moderate  dose.  Human  beings 
are  apparently  more  susceptible  to  tuberculin  than  are 
guineapigs. 

These  facts  tend  to  show  that  at  all  events  a  possible 
source  of  danger  resides  in  this  substance  when  it  is  used 
on  tuberculous  patients.  They  also  seem  to  prove  that,  as 
is  the  case  with  the  fever-producing  substance  noted  above, 
tuberculin  does  not  contain  a  substance  directly  poisonous 
in  itself,  but  rather  contains  some  material  which  interacts 
with  another  substance  present  in  infected  individuals, 
the  two  together  forming  a  poison.  The  reaction  would 
seem  to  be  analogous  to  the  phenomena  of  anaphylaxis 
described  on  p.  20,  though  certain  small  differences  have 
been  said  to  exist  between  them. 

After  the  reaction  has  subsided,  it  is  seen  in  many 
cases  that  an  improvement  in  the  local  disease  has  set  in, 
with  a  tendency  to  healing  in  what  may  have  previously 
been  an  indolent  sore.  The  tubercular  disease  of  the  skin 
known  as  lupus  vulgaris  is  the  form  of  tubercle  in  which 
this  result  is  best  seen,  but  the  same  phenomena  may 
take  place  in  any  focus  of  the  disease. 

There  is  no  doubt  of  the  fact  that  some  degree  of 
immunity  to  tubercular  infection  can  be  produced  in  animals 
by  injections  of  tuberculin.  Of  its  action  on  human  beings  it 
is  possible  to  obtain  some  indication  by  the  increased  power 


276       SERUMS,    VACCINES,    AND    TOXINS 

of  agglutinating  the  Bacillus  tuberculosis,  seen  in  the  blood- 
serum  of  such  patients  (see  p.  289),  and  by  its  effects 
on  the  opsonic  index.  It  is  not,  indeed,  certain  that  the 
immunity  of  the  individual  is  directly  proportionate  to 
either  of  these  properties,  but  there  is  evidence  to  suggest 
that  they  constitute  some  measure  of  the  resistance.  It 
seems,  however,  that  as  a  result  of  injections  of  tuberculin 
an  individual  may  acquire  a  tolerance  of  this  drug  without 
an  accompanying  immunity  to  tuberculosis. 

The  action  of  the  new  tuberculin  (T.R.)  is  quite 
different,  as  far  as  can  be  observed.  The  injection  of  a 
small  quantity  of  this — the  actual  substance  of  the  bacteria 
— causes,  indeed,  a  general  reaction  of  a  febrile  nature  in 
tuberculous  patients,  but  this  is  unconnected,  as  far  as  can 
be  seen,  with  changes  at  the  site  of  existing  lesions.  The 
curative  effect  of  the  injections  is  exerted  by  stimulating 
the  tissues  of  the  body  generally  to  form  antibodies  to  the 
tubercle  bacilli.  In  other  words,  the  new  tuberculin  is 
supposed  to  give  rise  to  a  condition  of  general  immunity. 
It  certainly  seems  to  have  the  power  of  raising  the  aggluti- 
nating power  of  the  serum,  and  also  its  opsonic  properties, 
and  there  is  reason  .to  believe  that  these  increase  pari  pa-ssn 
with  its  antibacterial  properties. 

Marmorek  maintains  that  an  interaction  takes  place 
between  the  tubercle  bacilli  themselves  and  the  tuber- 
culin ;  and  states  that  a  febrile  reaction  may  occur  if 
tuberculin  is  injected  almost  immediately  after  inoculation 
of  bacilli.  This  statement,  however,  is  not  confirmed  by 
other  observers. 

Patients  in  the  earlier  stages  of  tuberculosis  appear  to 
react  to  tuberculin  more  strongly  than  those  in  whom  the 
disease  is  more  advanced  ;  indeed,  those  in  the  third  stage  of 
phthisis  may  fail  to  give  any  reaction.  This  may  be  due  to 
the  fact  that  their  tissues  have  become  habituated  to  the 
toxins.  It  does  not  detract  from  the  practical  diagnostic 
value  of  the  drug,  since  it  is  in  the  early  stages  especially 
that  the  disease  is  difficult  to  recognize. 


EMULSION    OF    BACILLI  277 

Emulsion  of  bacilli. — Koch,1  as  we  have  seen  (p.  273), 
modified  his  procedure  in  the  matter  of  inoculation  in 
tuberculosis,  and  preferred  to  use,  instead  of  the  toxins 
of  the  bacilli  or  an  extract  of  their  body-substance,  the 
actual  bacilli  themselves.  Powdered  tubercle-bacilli  are 
suspended  in  50  per  cent,  solution  of  glycerin,  and  the  fluid 
is  allowed  to  stand  till  all  particles  of  any  appreciable 
size  have  sunk  to  the  bottom.  The  supernatant  emul- 
sion is  poured  off,  and  is  ready  for  use.  The  quantities 
are  adjusted  so  that  1  c.c.  of  the  fluid  contains  5  mg.  of 
powdered  bacilli.  For  use  it  is  diluted  with  normal  solu- 
tion of  sodium  chloride.  Koch  started  with  subcutaneous 
injections  calculated  to  contain  0'0025  mg.  of  the  solid 
material.  He  repeated  the  dose  every  two  days  or  so, 
raising  the  quantity  administered  each  time  to  twice,  or 
even  five  times,  the  amount  of  the  previous  dose.  No 
reaction  occurs  as  a  rule  with  the  first  small  doses.  It  may 
occur  as  the  dose  is  raised,  and  when  it  is  observed  the 
intervals  between  the  injections  must  be  prolonged  (eight 
days  or  so). 

The  agglutinative  power  of  the  serum  in  patients  so 
treated  rises  rapidly  in  the  great  majority  of  instances.  In 
a  minority  it  remains  stationary,  or  may  even  sink.  In 
such  cases  Koch  gave  intravenous  injections  of  a  fluid 
corresponding  with  his  earlier  T.O.  (see  p.  273),  but  only 
very  small  doses  can  be  administered  in  this  way.  Koch 
considered,  however,  that  the  intravenous  method  has  great 
advantages ;  and  after  introducing  it  he  in  many  cases 
started  with  the  subcutaneous  mode  of  injection,  and  had 
recourse  to  the  intravenous  method  afterwards  as  soon  as  a 
reaction  occurred  with  the  former. 

Koch  found  that  with  this  treatment  the  patients  gained 
appetite  and  weight,  night-sweats  ceased,  moist  sounds  dis- 
appeared from  the  lungs,  and  the  amount  of  sputum  was 
reduced.  The  presence  of  fever  is  not  a  contraindication 
to  this  treatment ;  indeed,  pyrexia  is  reduced  by  it. 
i  Deut,  med,  Woch.,  Nov.  25,  1901. 


278       SERUMS,    VACCINES,    AND    TOXINS 

MODIFICATK'XS   OF   TUBERCULIN 
Roughly,  the  different  forms  of  tuberculin  enumerated 
below  may  be  divided  into — 

Group  I.  Cultures  and  bacterio-proteins. 
,,     II.   Unheated  tuberculins. 

„  III.  Modifications     of     tuberculin     produced     by 
chemical  agents,  including  autolysates. 

It  is  generally  believed  that  all  tuberculins  contain  the 
same  active  substance,  the  different  preparations  varying  in 
concentration  and  in  the  nature  of  their  other  constituents. 

GROUP  I 

BOVINE    TUBERCULIN 

Spongier  and  Raw1  have  advised  the  use  of  a  tuberculin 
derived  from  cultures  of  bovine  bacilli  ("  Perlsucht  Tuber- 
culin": P. T.),  either  in  place  of  the  ordinary  preparation 
or  in  conjunction  with  it  (see  p.  273). 

VON   BUCK'S  TUBERCULIN 

This  is  a  watery  solution  or  extract a  of  tubercle  bacilli, 
comparable  with  Koch's  Oberer  Tuberkulin  (T.O.).  It  has 
been  used  in  the  United  States  with  good  results  (p.  327). 

VON   RUCK'S   PROPHYLACTIC 

Von  Ruck3  has  devised  a  method  of  active  im- 
munization against  tuberculosis  by  means  of  a  preparation 
made  as  follows :  An  old  and  non-virulent  culture  of 
tubercle  bacilli  is  washed  and  macerated  with  water 
containing  0*4  per  cent,  phenol ;  it  is  then  filtered  through 
porcelain,  the  filtrate,  containing  some  proteose  and  peptone, 

1   Deut.  med.  Woch.,  1908,  No.  38. 
-   Therapeutic  Gaz.,  1896,  p.  308. 
3   Med.  Record,  1912,  Ixxxii.  369. 


VARIETIES    OF    TUBERCULIN  279 

constituting  protein  No.  1.  The  bacillary  mass  is  further 
washed  and  extracted  with  ether,  dried  again,  powdered, 
and  extracted  with  water,  the  filtrate  being  protein  No.  2. 
A  third  process  of  powdering,  extracting,  and  filtering  gives 
protein  No.  3  ;  and  the  remnant  is  treated  with  0'4  per  cent, 
solution  of  sodium  hydrate,  and  filtered,  producing  protein 
No.  4.  The  vaccine  consists  of  0'25  parts  of  No.  1,  2*75 
parts  of  No.  2,  1  part  of  No.  3,  and  6  parts  of  No.  4,  and 
contains  10  mg.  of  solid  substance  in  1  c.c.  The  dose  for 
children  is  0*2  c.c.  to  0'6  c.c.,  for  infants  O'Oo  c.c. 

TUBERCULOPLASMIN 

Hahn,1  by  squeezing  the  bacilli  in  a  hydraulic  press, 
according  to  Buchner's  method,  prepared  a  fluid  to  which  he 
gave  the  name  of  "  tuberculoplasmin."  We  have  not  been 
able  to  find  any  record  of  its  employment  in  therapeutics. 

BACILLOSINE 

Levet2  grows  the  bacilli  for  three  months  and  then  distils 
the  cultures.  It  is  not  clear  from  his  account  whether  he 
then  uses  the  distillate  or  the  residue  for  immunizing  pur- 
poses— presumably  the  former.  The  preparation  is  made 
in  several  strengths — No:  0,  1  per  cent.  ;  No.  1,  2  per  cent.  ; 
and  No.  2,  3  per  cent.  It  may  be  used  as  a  prophylactic. 


A  remedy  sold  under  this  name  is  said  to  be  an 
albuminous  substance  (tubei-culo-albumin)  derived  from  the 
bodies  of  tubercle  bacilli.  It  is  a  greyish-white  substance, 
and  for  use  is  dissolved  in  a  0'3  per  cent,  solution  of  phenol. 
It  is  administered  by  the  mouth  in  doses  of  10  to  40  drops. 
We  have  not  been  able  to  find  the  article  in  which  it  was 
originally  described  by  its  inventor,  Thamm. 

1  Quoted.by  Shaw,  Lancet,  1908,  i.  926. 
3  Arch.  Gen.  de  Med.,  1906,  cxcvii.  965. 


280       SERUMS,    VACCINES,    AND   TOXINS 

TULASE    (TUBEKCULASE) 

Beh ring  announced  the  preparation  of  an  extract  of 
tubercle  bacilli  (tulase)  from  which  toxic  matters  have 
been  removed  and  which  he  believes  will  be  useful  for 
treatment  and  prophylaxis.  The  exact  manner  in  which 
the  substance  is  prepared  has  not  been  published,  and  so  far 
the  remedy  is  not  generally  procurable.  Collin,1  who  used 
some  of  it  in  certain  cases  of  ophthalmic  tuberculosis,  speaks 
of  it  as  a  wax-like  residue  which  separates  from  the  bacilli 
when  they  are  rubbed  up  with  chloral  hydrate  and  left  to 
stand.  The  doses  given  were  O'Ol  nig.  to  8  nig.  Tulase 
does  not  appear  to  have  been  employed  in  the  treatment  of 
any  large  series  of  cases.  An  immune  serum  or  antitutase) 
prepared  by  injecting  animals  with  tulase,  may  also  be  used 
to  induce  a  passive  immunity.  Nothing  has  been  heard  of 
this  preparation  for  the  last  few  years. 

BRUSCHETTINI'S  SERO-VACCINE 

Bruschettini2  prepared  an  antitubercular  serum  by  inject- 
ing horses  with  successive  doses  of  (a)  bacilli  killed  by  a 
temperature  of  60°  C.  ;  (b)  of  endotoxin  derived  by  extrac- 
tion of  bacilli  with  0-5  per  cent,  phenol  solution  ;  (c)  of 
bacilli  which  had  been  placed  in  collodion  sacs  within  the 
peritoneal  cavities  of  immunized  animals ;  (d)  of  an  extract 
of  the  lungs  of  rabbits  which  had  received  injections  of 
tubercle  bacilli  and  of  endotoxin,  and  of  (e)  a  leucocytophil 
substance ;  and  finally  (/)  of  living  virulent  bacilli.  The 
serum  from  these  horses  was  mixed  with  bacilli  which  had 
been  kept  in  contact  with  leucocytes — presumably  in  the 
pleural  cavities  of  rabbits  or  guineapigs.  This  sero-vaccine 
(sensitized  vaccine)  was  tried  at  Brompton  Hospital  by 
Hector  Mackenzie  and  A.  C.  Inman,but,  though  Bruschettini 

1  Miineh.  med.  Woch.,  1907,  No.  36. 

2  Internat.   Congr.  of  Tub.,  Brussels,  1910  ;    XVIIth  Internat. 
Congr.  of   Med.,  London,  1913  ;    Xlth  Internat.  Anti-Tub.    Couf.. 
Berlin,  1913. 


VAKIETIES    OF    TUBERCULIN  281 

speaks  warmly  of  the  results  achieved,  Inman  l  was  unable 
to  discover  any  valuable  effects.  A  modified  form  of  the 
vaccine  is  also  prepared  for  separate  use. 

DIXON'S  TUBERCULIN2 

Mixed  human  and  bovine  cultures  are  dried,  washed 
several  times  in  ether  to  remove  the  fatty  coat,  ground  in  a 
mortar,  and  suspended  in  saline  solution  (1  part  in  5  of 
fluid).  The  suspension  is  well  shaken  for  several  hours 
and  then  allowed  to  stand  for  several  days,  after  which  it 
is  filtered  free  of  organisms.  The  stock  solution  contains 
0-5  grin,  of  bacillary  substance  in  1  c.c.  The  doses  advised 
are  O'OOl,  O01,  0*02  grm.,  and  so  forth,  given  every  five 
or  seven  days.  Francine  and  Hartz3  speak  well  of  this 
preparation  in  chronic  cases  of  pulmonary  disease. 

FRIEDMANN'S   TUBERCULIN 

Friedmann4  made  a  communication  to  the  Berlin 
Medical  Society  in  November,  1912,  in  which  he  stated 
that  he  had  had  good  results  in  the  treatment  of  tuber- 
culosis by  injection  of  a  vaccine  consisting  of  living 
bacilli  derived  from  tubercular  lesions  in  cold-blooded 
animals.  His  paper  was  said  to  be  founded  on  the  ex- 
perience gained  in  application  of  the  remedy  in  1,012 
cases.  Favourable  opinions  were  expressed  by  some  who 
had  tried  the  preparation — Karfunkel,  Schleich,  Miiller, 
Thalheim,  and  others.  It  is  given  hypodermically  or 
intramuscularly,  and  causes  the  appearance  of  local  in- 
duration and  sometimes  of  abscess-formation.  Later 
experiences  with  this  tuberculin  have  not  been  encouraging 
(Mannheimer,5  Barnes6 ),  and  a  journey  to  the  United 

1  Personal  communication. 

2  Dixon,  Pennsylv.  Health  Bull.,  Oct.,  1911. 

3  Journ.  Amer.  Mad.  Asaoc.,  March  8,  1913. 

4  Berl.  klin.  Woch.,  1912,  xlix.  2214,  2241. 

5  Ibid.,  1913,  p.  1301. 

6  Providence  Heel,  Journ,,  Nov.,  1913. 


282       SERUMS,    VACCINES,    AND    TOXINS 

States  undertaken  by  Friedmann  to  demonstrate  his 
preparation  was  far  from  leading  to  acceptance  of  his 
claims  in  that  country.  It  is  said  that  in  some  cases  which 
died  there  was  found  a  rniliary  tuberculosis  of  the  muscles 
near  the  site  of  injection  — a  condition  from  which 
alarming  inferences  have  been  drawn  as  to  the  possible 
danger  inherent  in  the  use  of  this  tuberculin.  It  must, 
however,  be  borne  in  mind  that  dead  bacilli  may  give  rise 
to  tubercles  where  they  settle,  and  living  bacilli  of  foreign 
type  might  theoretically  also  do  so  and  yet  not  possess  the 
power  of  causing  a  spreading  generalized  tubercular  in- 
fection. The  preparation  is  stated  to  be  quite  harmless  to 
guineapigs. 

A  very  similar  remedy  was  prepared  by  Piorkowsky, 
who  lectured  on  it  in  this  country  and  presented  some  of  it 
for  trial  at  the  Brompton  Hospital.  It  consisted  of  a  nitrate 
corresponding  with  Old  Tuberculin  and  a  suspension  of 
bacilli  corresponding  with  B.E.,  both  obtained  from  cultures 
of  bacilli  derived  from  a  turtle.  Trial  in  a  few  cases  at  the 
above  hospital  did  not  produce  a  favourable  impression  as 
to  its  value.  The  routine  advised  was  the  administration 
subcutaneously  or  intramuscularly  of  two  doses  of  suspension 
of  bacilli  (0-5  and  1  c.c.  respectively)  at  a  week's  interval, 
followed  by  injections  of  the  filtrate  0*1,  0'2,  0'5  c.c.,  and 
so  forth.  No  good  effects  were  observed.  In  one  case 
an  abscess  formed  some  three  months  after  the  injection. 
Another  patient,  who  left  the  hospital  improved  to  some 
extent,  was  readmitted  within  a  few  weeks,  and  died  with 
an  acute  broncho-pneumonic  tuberculosis. 

ROSENBACH'S   TUBERCULIN 

This  preparation  is  made  by  growing  Trichophyton 
holosericum  on  cultures  of  tubercle  bacilli  (six  to  eight 
weeks  7}ld)  in  glycerin-bi'oth  at  20°— 22°  C.  for  a  period  of 
ten  to  twelve  days ;  separating  the  growth,  which  is  rubbed  up 
in  saline  solution  and  filtered  free  of  organisms ;  adding  the 
culture-fluid,  which  has  also  been  filtered  so  as  to  be  germ- 


VARIETIES    OF    TUBERCULIN  283 

free ;  and  making  the  whole  up  to  ten  times  the  volume  of 
the  mass  of  tubercle  bacilli  and  trichophytoii  used.  The 
idea  underlying  this  mode  of  preparation  is  that  the 
trichophyton  destroys  some  of  the  toxic  bodies  formed  in 
the  growth  of  the  tubercle  bacilli,  while  the  immunizing 
principle  remains  unaffected.  The  result  is  a  clear  brown 
liquid,  1  c.c.  of  which  contains  the  extract  of  12 '5  mg.  of 
bacillary  substance.  The  doses  used  are  large,  compared 
with  other  tuberculins,  viz.  O'Ol,  O'l,  0'2  c.c.  Rosenbach1 
advises  the  use  of  his  tuberculin  in  all  kinds  of  tubercu- 
losis. It  appears  to  be  a  very  weak  preparation,  Lesser 
and  Kogel2  stating  that  it  is  1,000  times  weaker  than 
Koch's  O.T.,  while  Schafer  3  regards  it  as  practically  inert. 
Kausch  4  finds  it  useful  in  surgical  tuberculosis,  and  Kohler 
and  Plaut "'  in  pulmonary  disease. 

TUBERCULOMUCIN 

Weleminsky G  grew  cultures  of  tubercle  bacilli  for  a 
prolonged  period  of  time,  and  found  that  nucleo-protein, 
albumin,  and  finally  mucin  were  formed  in  the  process. 
After  a  time  growth  ceases,  but  the  culture-fluid  becomes 
fertile  again  on  heating.  This  suggests  that  cessation  of 
growth  is  due  not  to  exhaustion  of  nutritive  material,  but  to 
formation  of  an  antibody.  Weleminsky  prepares  a  form  of 
tuberculin  from  his  cultures,  the  exact  mode  of  preparation 
of  which  we  have  not  found  recorded.  Pachner,7  who  tried 
it  on  35  patients,  found  that  it  gave  good  results  even  in 
advanced  cases.  For  use  he  dilutes  the  original  fluid  with 
saline  solution,  1:10,  and  gives  ^  c.c.  of  the  dilution.  The 
doses  are  doubled  each  time,  injections  being  given  weekly. 

1Dei<tJmed.'Woch.,  1910,  p.  1513. 
*£eitr.z.  Klin.  d.  Tuberk.,  1913. 

3  Zeitschr.  f.  Tuberk.   1912,  xii.,  Heft  2. 

4  Deut.  med.  JToch.,  1913,  p.  252. 

5  Zeitschr.  f.  Min.  Med.,  1912,  Ixxiv.,  Hefte  3  u.  4. 
«  Berl.  Min.  Woch.,  1912,  p.  1321. 

7  Beitr.  z.  Klin.  d.  Tuberk.,  1912,  xxv.  137. 


284       SERUMS,    VACCINES,    AND   TOXINS 

GROUP  II 

TUBERCULOCIDIN   AND   ANTJPHTHISIN 

It  has  been  suggested  that,  in  the  process  of  preparing 
tuberculin  usually  adopted,  some  of  the  constituents  of  the 
bacterial  culture,  which  are  volatile,  are  driven  off  by  the 
heat.  Tuberculin  also  contains  some  ingredients  which 
are  harmful  rather  than  curative.  Klebs  therefore  devised 
modifications  of  tuberculin,  prepared  without  heating,  to 
which  he  gave  the  names  of  "  tuberculocidin  "  and  "  anti- 
phthisin."  The  method  of  manufacturing  the  former  is 
complicated,  consisting  in  frequent  precipitation,  and 
solution  of  the  precipitate,  by  alcohol  and  other  reagents. 
Tuberculocidin  is  said  to  kill  the  bacilli  when  it  is  added  to 
a  culture  of  them  in  vitro. 

Klebs1  claims  good  results  from  the  use  of  his  preparation, 
and  a  large  amount  of  antiphthisin  is  said  to  be  used  in 
America.  The  therapeutic  dose  of  tuberculocidin  is  1  eg. 
to  start  with,  the  fluid  as  sold  being  diluted  before  use 
(1  :  10).  Antiphthisin  is  more  concentrated,  and  half  the 
above  quantity  is  administered. 

Tuberculocidin  may  also  be  administered  by  the  mouth, 
and  is  said  to  act  as  well  or  even  better  by  this  channel. 
It  may  be  applied  locally  to  tubercular  lesions,  and  forms 
an  efficient  dressing  for  ocular  ulcers,  tuberculides,  etc. 
Disease  of  bones  and  joints  also  improves  under  treatment 
with  this  remedy  ;  in  cases  of  tubercular  hip-disease  it 
should  be  injected  in  the  neighbourhood  of  the  joint. 
Tuberculocidin  is  said  to  have  a  favourable  influence  in 
cases  of  genito-urinary  tuberculosis. 

Jessen  2  states  that  the  remedy  is  not  free  from  danger. 
He  gives  doses  of  20  to  25  drops,  finding  that  larger  doses 
may  produce  a  reaction  like  that  seen  with  the  old  tubercu- 
lin. He  reports  good  effects  from  the  use  of  tuberculocidin 

1  Munch,  med.  Woch.,  1904,  p.  1688. 

2  Centralbl.  /.  inn.  Med.,  1902,  No.  23,  p.  585. 


VARIETIES    OF    TUBERCULIN  285 

in  phthisis — fall  of  temperature,  diminution  in  the  amount  of 
sputum,  and  feeling  of  improvement.  All  his  cases  in  the 
first  stage  of  the  disease  showed  improvement  (100  per 
cent.),  and  54  per  cent,  of  those  in  the  second  stage. 
Jessen  thinks  the  remedy  worthy  of  further  trial. 

There  does  not  seem  to  be  sufficient  evidence  available 
as  to  the  curative  effects  of  these  preparations,  which  are 
now  seldom  if  ever  prescribed.  Klebs  claims  60  per  cent, 
of  cures  among  his  cases,  which  does  not  seem  a  startling 
figure. 

DENYS'  TUBERCULIN   (BOUILLON  FILTHK) 

This  is  prepared  in  a  manner  similar  to  Koch's  T.,  but 
without  the  use  of  heat.  It  is  sent  out  in  eight  different 
strengths,  named  respectively 

To        To      To    To  .       .. 

io^oo'  T^oo'  100'  lo"'  10'  "•  ln>  1U1' 

each  being  ten  times  the  strength  of  that  preceding  it,  so 
that  a  gradual  increase  of  dose  is  facilitated.1 

TUBERCULOL  (TL.) 

Landmann2  devised  this  form  of  tuberculin  with  a  view 
to  avoiding  the  use  of  heat,  which  may  destroy  some  of 
the  immunizing  substances  of  tuberculin  when  it  is  made 
according  to  Koch's  formula.  He  took  cultures  of  human 
bacilli  made  virulent  by  passage  through  animals,  and  ex- 
tracted them  with  distilled  water,  first  at  room  temperature, 
for  a  considerable  time.  The  supernatant  fluid  was  then 
decanted,  and  the  bacilli  macerated  again  with  successive 
fresh  quantities  of  water  at  temperatures  of  60°,  80°,  and 
100°  C.,  the  liquid  being  each  time  similarly  decanted.  The 
materials  thus  obtained  were  mixed  together,  concentrated 
in  vacuo,  and  filtered  through  porcelain,  and  the  resulting 
sterile  fluid  constitutes  Tuberculol  B.  The  fluid  in  which 

1  Bull.  E.  Acad.  Med.  Belg.,  xvi.  499  ;  see  also  Sahli,  "  Ueber  Tuber - 
kulinbehandlung,"  1907. 

3  Hygien.  Rundschau,  1900,  x.  361, 


280       SERUMS,    VACCINES,    AND    TOXINS 

the  residue  of  the  bacilli  remained  suspended  was  next 
filtered  from  the  solid  mass  and  constitutes  Tuberculol  C, 
while  a  mixture  of  this  with  the  previously  described 
Tuberculol  B  constitutes  Tuberculol  A.  The  preparation  is 
standardized  so  that  1  c.c.  contains  the  minimum  lethal 
dose  for  a  healthy  guineapig.  Von  Hoi  ten,1  who  recom- 
mends this  form  of  tuberculin,  starts  with  a  small  close, 
such  as  loiF.inro  c.c.,  of  Tuberculol  B,  which  he  prefers  to 
the  other  brands. 

BERANECK'S    TUBERCULIN 

Beraneck  2  has  prepared  a  form  of  tuberculin  (T.B.K.) 
which  he  considers  to  be  less  toxic  than  Koch's.  He  obtains 
a  toxin  (basitoxin,  B.T.)  by  growing  the  bacilli  in  veal-broth 
rendered  slightly  alkaline  with  calcium  hydrate,  at  a  tem- 
perature of  37°  to  38°  C.,  and  evaporating  the  fluid  in  vacua 
without  heating.  This  is  mixed  with  an  equal  quantity 
of  a  second  toxin  (acidotoxin,  A.T.)  extracted  from  the 
bodies  of  the  bacilli.  The  preparation  is  sent  out  in  a  series 
of  different  dilutions, 


the  last  being  the  pure  tuberculin,  and  each  of  the  former 
brands  being  half  the  strength  of  that  following  it. 

Sahli  3  has  used  the  preparation  with  good  effect,  and 
finds  the  series  of  dilutions  convenient.  He  starts  with 

7T0-  c.c.  of  the  dilution  ~,  and  increases  the  dose,  if  no  result 

ensues,  by  successive  amounts  of  A  c.c.;  he  then  uses  the 
stronger  solutions  successively.  The  injections  are  given 
twice  a  week,  or  less  frequently. 

Good  results  in  cases  of  pulmonary  tuberculosis  were 
also  obtained  by  Paris,1  who  employed  slightly  different 
solutions. 

1  Beitr.  z.  Klin.  d.  Tuber/.-.,  1«»12,  Suppl.  IV.,  p.  IOC  (188). 

2  See  Semaine  MM.,  1903,  p.  393. 
8  Op.  supra  cit. 

1  liev.  Med.  de  la  Suisse  Romande,  1904,  No.  10,  p.  629. 


VARIETIES    OF    TUBERCULIN  287 


GROUP  III 

OXYTUBERCUL1N 

Hirschf elder1  believed  that  toxins  were  converted  into 
antitoxins  by  a  process  of  oxidation,  and  consequently 
prepared  a  modification  of  tuberculin,  which  he  called  "  oxy- 
tuberculiri,"  by  treating  the  ordinary  substance  with  hydro- 
gen peroxide.  The  hypothesis  upon  which  the  procedure 
is  founded  seems  quite  unsupported  by  evidence,  and  no 
records  of  the  employment  of  the  remedy  are  available. 

TUBERCULOTOXOIDIN 

Ishigama2  gave  this  name  to  a  solution  of  tubercle  bacilli 
in  sulphuric  acid,  which  he  found  to  have  some  immunizing 
value  and  to  raise  the  opsonic  index.  He  also  makes  use 
of  a  serum  prepared  from  animals  immunized  with  this 
substance  ("  tuberculo-toxoidin  immune  serum  "). 

TUBERCULIN   CL.   (CALMETTE) 

Calmette  prepares  a  special  form  of  tuberculin,  which 
was  originally  intended  for  the  ophthalmic  test,  but  which 
has  since  been  used  for  treatment.  Broth-cultures,  six 
weeks  old,  of  bovine  tubercle  bacilli,  are  heated  in  the 
autoclave  at  110°  C.  for  twenty  minutes.  They  are  then 
evaporated  on  a  water-bath  at  80°  C.  to  one-tenth  of  their 
original  volume,  and  filtered.  The  filtrate  is  precipitated 
with  95  per  cent,  alcohol,  and  dried  in  vacuo  ;  it  is  then 
dissolved  again  in  water,  once  more  precipitated  with 
alcohol,  and  dried.  The  resulting  powder  is  dissolved 
in  sterile  water  for  use,  and  is  injected  subcutaneously  in 
graduated  doses',  from  0*001  mg.  to  1  mg.,  at  intervals  of 
twelve  days. 

1  Deut.  med.  Woch.,  1897  ;  Therap.  Beilage,  25. 
a  Ishigama   and_  Matsuda,  Abstr.  in  Centralbl.   f.  Bttkt.,  I-  Ref., 
1908,  xli.  100. 


288       SERUMS,    VACCINES,    AND    TOXINS 

IODIZED  TUBERCULIN 

Bauer  and  Murschhausen,1  and  also  Kapsenberg,2  have 
prepared  a  combination  of  tuberculin  with  iodine. 
Kapsenberg's  method  is  to  take  the  mass  of  bacilli  left 
in  the  preparation  of  tuberculin,  and  to  rub  it  up  with 
chloroform  in  a  mortar.  After  the  addition  of  more 
chloroform  the  liquid  is  centrifuged,  when  it  divides  into 
three  layers,  the  bacilli  remaining  in  the  middle  one.  The 
top  layer  is  a  yellowish  liquid  which  readily  takes  up  iodine, 
1  c.c.  absorbing  5-10  drops  of  a  saturated  solution  in 
9G  per  cent,  alcohol.  The  tuberculin  thus  formed  is  said  to 
protect  guineapigs  against  infection. 

IRON-TUBERCULIN 

Schultz  3  devised  a  preparation  derived  from  Old  Tuber- 
culin by  the  addition  of  12  per  cent,  solution  of  iron 
oxychloride  to  a  dilute  watery  solution  (10  c.c.  tuberculin 
with  50  c.c.  water)  of  Koch's  preparation.  A  precipitate 
forms,  which  is  collected  and  dissolved  in  1  per  cent, 
caustic-soda  solution.  A  sufficient  quantity  of  25  per  cent, 
glycerin  solution  is  added  to  prevent  decomposition.  The 
result  is  a  clear,  brownish,  opalescent  liquid,  the  close  of 
which  is  O'Ol  mg.,  rising  by  multiples  of  1-3,  1*7,  2'2,  3'5, 
4'5,  6,  8,  10.  Schellenberg*  reports  favourably  of  this  iron- 
tuberculin  (Eisentuberkulin),  which  can  be  used  both  for 
diagnosis  and  treatment.  It  is  much  weaker  than  O.T., 
resembling  in  strength  albumose-free  tuberculin,  and  can 
be  safely  used  in  out-patient  practice. 

SANOCALCIN  TUBERCULIN 

On  the  ground  that,  ex  pei-imen  tally,  calcium  salts  aid 
phagocytosis  (Hamburger  and  Hekma"'),  Sticker  devised  a 

1  Beitr.  z.  Klin.  d.  Tuberk.,  Suppl.  iii.,  1912,  p.  13. 

2  Berl.  klin.  track.,  1912,  p.  897. 

3  Ibid.,  1909,  p.  1721. 

4  Zeitsckr.f.  Tuberk.,  1912,  xviii.  132. 

5  Biochem.  Zeitschr.,  1907,  No.  3. 


VARIETIES    OF    TUBERCULIH  289 

preparation  combining  this  element  with  tuberculin.  The 
composition  of  the  preparation  is — G'0005  grm.  tuberculin 
and  O'Ol  calcium  glycero-lacto-phosphate  in  1  c.c.  of  sterile 
saline  solution.  It  is  sold  in  ampulla?,  and  the  dose  for 
starting  treatment  is  O'00005-O'OOOl  grm.  tuberculin,  sub- 
sequent doses  rising  by  multiples  of  2,  and  being  given 
every  two  or  three  days.  Korb 1  states  that  the  preparation 
produes  no  febrile  reaction  or  other  ill  effects,  but  a  marked 
focal  reaction  in  pulmonary  disease.  He  believes  it  to  be  a 
useful  remedy. 

TEBEAN 

This  form  of  tuberculin,  devised  by  Levy,2  is  made  by 
shaking  up  human  tul>ercle  bacilli  with  25  per  cent,  solution 
of  galactose  for  four  and  a  half  days  at  37°  C.  The  resulting 
material  is  then  dried  in  vacuo,  and  standardized  so  that 
1  grm.  of  the  powder  contains  1  mg.  of  dried  bacillary 
substance.  It  is  said  to  have  some  immunizing  power  in 
guineapigs,  those  injected  with  tebean  living  longer  than 
control  animals,  and  showing  at  times  cavity-formation  in 
the  lungs,  a  sign  of  chronic  disease  due  to  increased  resist- 
ance. For  therapeutic  use  the  powder  is  dissolved  in  sterile 
saline  solution,  the  doses  rising  from  T^^  mg.  to  4  mg.  and 
being  given  once  or  twice  weekly.  Steffen3  records  good 
results  "from  the  use  of  this  preparation. 

SERUM   DIAGNOSIS 
Agglutination  test  for  tuberculosis.— It  is  found 

that  the  blood  of  a  patient  suffering  from  tuberculosis  has 
the  power  of  causing  a  clumping  of  tubercle  bacilli  in  the 
same  way  as  that  of  a  typhoid  patient  agglutinates  the  B. 
typhosus.  Use  was  made  of  this  property  by  Arloing  and 
Courrnont 4  to  detect  the  presence  of  tuberculosis. 

1  Zcitschr.  /.  Tuberl;,,  1913,  x'x.  339. 

2  Levy  and  Krencker,  Ztltsthr.-f.  Immunitcitsf<>rsc1i.,  Orig'.,  1909,, 
iv.  286. 

3  Munch,  med.  Woch.,  April  19,  1910,  p.  838, 

4  Ga:.  dcs  Sop.,  1900,  p.  146". 

T 


290       SERUMS,    VACCINES,    AND    TOXINS 

Preparation  of  the  emulsion. — In  the  case  of  the 

tubercle  bacillus  a  preliminary  difficulty  arises,  which  is 
not  found  in  working  with  the  13.  typhoms,  in  that  the 
former  organism,  when  grown  in  the  laboratory  on  ordinary 
culture-media,  occurs  in  masses  which  are  already  closely 
agglutinated.  It  is  necessary,  therefore,  for  the  purpose  of 
the  test,  to  prepare  the  bacilli  in  some  special  way  so  that 
they  are  separated  one  from  another.  This  was  first 
accomplished  by  Arloing1  by  the  following  method  of  pro- 
cedure :  Suitable  potatoes  are  taken  and  boiled,  and  slices 
of  them  are  put  into  the  usual  laboratory  potato-tubes.  At 
the  bottom  of  the  tubes  is  placed  a  small  quantity  of  a 
6  per  cent,  solution  of  glycerin  in  water,  so  that  the  fluid 
just  touches  the  lower  part  of  the  potato.  The  tubes  thus 
prepared  are  sterilized  for  forty-five  minutes  in  the  auto- 
clave. The  surfaces  of  the  slices  of  potato  are  then  inocu- 
lated with  tubercle  bacilli  derived  from  a  human  source, 
and  the  cultures  are  incubated  at  a  temperature  of  38° 
to  39°  C.  On  every  second  day  the  tubes  are  tipped 
up,  so  that  by  their  inclination  the  glycerin  solution 
is  caused  to  flow  over  the  cultures  on  the  surface  of  the 
potato.  Growth  occurs  rapidly  in  these  circumstances, 
the  resulting  masses  of  organisms  being  different  from  the 
ordinary  cultures  on  glycerin-agar,  in  that  they  are  soft  in 
consistency,  and  easily  broken  up  by  the  application  of  a 
glass  rod,  or  by  rubbing  in  a  mortar.  From  these  cultures 
sub-cultures  are  made  in  glyceriuated  veal-broth  (1  per 
cent,  peptone  and  6  per  cent,  glycerin).  These  are  submitted 
to  daily  shaking  to  keep  the  organisms  separate  one  from 
another.  Even  in  these  cultures  it  is  impossible  to  prevent 
a  certain  amount  of  clump-formation,  but  the  majority  of 
the  organisms  present  are  separate,  and  the  fluid  is  turbid 
and  fairly  homogeneous,  with  but  little  sediment. 

It  is  interesting  to  note    that,   grown  under  the  con^ 
ditions  indicated,  the  bacilli  are  described  as  motile,  some 
writers   even   attributing   to   them   a   degree   of    motility 
1  Compt.  Send.  Acad.  Sci.,  1898,  cxxvi.  1319. 


AGGLUTINATION    TEST  291 

equal  to  that  of  the  Bacillus  typhosus.  Branching  forms 
are  also  met  with.  Koch  at  one  time  doubted  the  identity 
of  the  bacilli  described  by  Arloing  and  Courmont  with  his 
own  bacilli. 

Some  writers  advise  that,  before  they  are  used  for  the 
agglutination  test,  the  organisms  should  be  transferred 
through  a  series  of  broth-cultures,  holding  that  they  thus 
become  more  motile,  are  better  separated,  and  grow  more 
rapidly.  Loeb1  does  not  recommend  this  procedure,  as 
he  has  found  that  it  is  impossible  to  grow  the  bacilli  beyond 
the  fourth  generation.  This  observer  has  failed  to  discover 
active  movement  in  the  bacilli,  though  the  usual  Brownian 
movement  may  be  seen. 

The  broth-culture  should  be  grown  for  a  period  of  from 
nine  to  fifteen  days,  and  then  used  for  the  test.  Before  the 
eighth  day  there  are  not  enough  bacilli  present,  while  after 
the  fifteenth,  spontaneous  agglutination  may  take  place,  and 
the  reaction  with  serum  is  often  lessened  at  this  time.  The 
test-fluid  can  be  preserved  in  a  condition  fit  for  use  by 
keeping  it  on  ice,  or  by  the  addition  of  a  minute  quantity  of 
some  antiseptic,  e.g.  formalin  (1  :  400),  or  carbolic  acid; 
both  methods  may  be  combined.  Some  such  mode  of 
preservation  is  necessary,  as  the  labour  of  making  a  separate 
culture  for  every  experiment  would  be  enormous. 

Mode  of  performing'  the  test. — The  mode  of  apply- 
ing the  test  is  as  follows  :  Clear  blood  -  serum  or  inflam- 
matory fluid  from  a  patient  suspected  of  tuberculosis  is 
added  in  varying  pi-oportions  to  a  series  of  tubes  of  the 
suspended  bacilli.  The  tubes  are  placed  in  an  incubator  for 
a  period  of  two  to  six  hours,  inclined  at  an  angle  of  45°.  If 
they  are  allowed  to  remain  for  a  longer  period,  for  instance 
twenty-four  hours,  as  was  at  first  recommended,  normal 
serum  may  give  rise  to  a  certain  amount  of  agglutination. 
If  the  reaction  be  positive,  the  serum  gradually  appears  less 
opaque,  a  flocculent  precipitate  falling  to  the  bottom.  This 
is  visible  with  the  unaided  eye,  on  examination  in  a  bright 

1  Journ.  ofAmer,  Med.  Assoc.,  May  23,  1903,  pp.  1,  423,  etc. 


292       SERUMS,    VACCINES,    AND    TOXINS 

light  against  a  dark  background.  A  control  experiment 
should  be  made,  for  purpose  of  comparison,  with  normal 
serum.  Microscopically,  it  will  be  seen  that  the  bacilli  are 
clumped  as  in  the  "  Widal  test "  for  enteric  fever.  The 
test  in  tuberculosis  is  not,  however,  so  well  marked  as  in 
the  former  disease.  Errors  may  occur  owing  to  the  presence 
of  small  tibrinous  coagula,  especially  when  inflammatory 
exudates  are  -employed  for  the  test.  It  is  necessary  to 
make  certain  by  means  of  the  microscope  that  any  apparent 
clumps  are  in  reality  formed  of  bacilli.  Staining  reagents 
may  be  needed  to  decide  in  cases  of  doubt.  It  must  be 
borne  in  mind  that  a  certain  proportion  of  clumped  bacilli 
may  occur  in  the  cultures,  however  carefully  they  are  pre- 
pared :  hence  arises  the  importance  of  invariably  making 
use  of  a  control  experiment. 

Simplification  of  the  procedure.  --  The   process 

adopted  by  Arloing  and  Courmont  is  very  long  and  tedious, 
and  modifications  have  been  suggested  for  the  purpose  of 
simplifying  it.  Thus,  Romberg  prepared  a  suspension  of 
the  bacilli  by  macerating  dried  cultures  with  a  1'5  per 
cent,  solution  of  caustic  soda,  and  then  neutralizing  with 
acetic  acid.  Koch1  described  a  still  simpler  method.  An 
ordinary  culture  is  taken  and  dried  by  pressure  between 
pieces  of  blotting-paper.  A  known  quantity  of  it  is  then 
weighed  out  and  rubbed  up  in  a  mortar  with  a  weak 
solution  of  caustic  soda.  Instead  of  this  a  culture  may 
be  dried  and  triturated  in  a  mortar  to  a  fine  powder. 
A  weighed  quantity  of  the  powder  (O'l  gr.)  is  macerated 
with  saline  solution,  added  in  quantities  of  a  few  drops 
at  a  time,  till  the  original  culture  is  diluted  to  1  :  100. 
The  solid  residue  is  then  separated  by  the  centrifuge,  and 
the  supernatant  fluid  is  decanted  and  diluted  with  a  fresh 
amount  of  salt-solution,  to  which  a  small  amount  of  carbolic 
acid  is  added,  till  the  dilution  reaches  1  :  1,000.  This  fluid 
can  be  kept  without  alteration  owing  to  the  presence  of 
the  carbolic  acid.  For  use  it  is  again  diluted  to  1  :  10,000, 
1  Deut.  tiied.  jrodt.,  Nov.  28,  1901. 


AGGLUTINATION  IN   TUBERCULOSIS      293 

but  this  last  dilution  seems  unnecessary  and  almost  dis- 
advantageous. If  a  strongly  clumping  serum  is  added  to 
the  fluid  in  the  proportion  of  1  :  10  or  1  :  25,  agglutination 
rapidly  occurs.  This  is  aided  by  a  moderate  degree  of 
warmth,  as  by  holding  the  test-tube  in  the  hand.  The 
reaction  takes  place  much  more  quickly  in  the  stronger 
fluid  (1  :  1,000)  than  in  the  extreme  dilution.  The  time- 
limit  recommended  by  Koch  is  fifteen  to  twenty  hours.  A 
good  plan  is  to  put  the  tubes  in  the  incubator  overnight, 
and  to  examine  them  in  the  morning.  Koch  employed  dilu- 
tions of  serum  of  1  :  10,  1  :  25,  1  :  75,  1  :  100,  and  so  on, 
in  a  series  of  tubes.  The  serum  is  first  poured  into  the  test- 
tube  and  the  fluid  containing  the  bacilli  is  added,  and  the 
mixture  shaken  up.  A  control  test  is  always  necessary. 

Koch  advised  removal  of  the  serum  needed  by  means  of 
a  cupping-glass,  while  Arloing  and  Courmont  draw  blood 
from  a  vein  and  remove  the  corpuscles  by  the  centrifuge. 
Shibayama '  recommends  for  this  test  the  use  of  organisms 
freed  from  fat  by  extraction  with  alcohol  and  ether,  and 
made  into  a  homogeneous  emulsion. 

Agglutinative    power   in   human   beings.  —  In 

human  beings  it  is  found  that  the  serum  of  those  who  are 
not  suffering  from  tuberculosis  may  at  times  possess  an 
agglutinative  power.  Infants  and  young  children  do  not 
seem  to  give  a  reaction,  but  adults  may  do  so.  Thus,  of  30 
non-tuberculous  persons,  5  gave  a  reaction  in  dilutions  of 
1  :  25,  1  at  1  :  50.  In  one  case  a  subsequent  post-mortem 
examination  proved  the  absence  of  tubercular  infection. 
Of  78  phthisical  cases,  only  14  gave  a  positive  reaction 
in  dilutions  of  1  :  10,  1  case  at  1  :  50,  4  at  1  :  25.  In 
several  cases  of  tuberculosis  affecting  other  regions  (bladder, 
bone,  etc.)  no  reaction  was  obtained. 

Arloing  and  Courmont  give  the  following  statistics  of 
results  :    Of  191  persons  presenting  clinical  signs  of  tuber- 
culosis, 168  or  87 '9  per  cent,  reacted  positively,  while  23  or 
12'1  per  cent,  were  negative.     Of  130  cases  clinically  non- 
1  Perl.  klin.  Woch.,  1911,  p.  341, 


291       SERUMS.    VACCINES,    AND    TOXINS 

tuberculous,  4~>  reacted  (34-6  per  cent.),  85  (65-4  per  cent.) 
were  negative.  Among  41  healthy  persons,  11  reacted 
(26-8  per  cent.),  while  30  were  negative  (73 '2  per  cent.). 
In  all  these  cases  blood-serum  was  employed  for  the  test. 
Serous  effusions  gave  the  following  results  : — 

Positive  Negative 

Tubercular  pleural  effusions    (31)       ...       23  ...         8 

Pleurisy  of  doubtful  oi-igin     (16)       ...       13  ...         3 

Non-tuberculav  hydrothorax  (11)       ...         0  ...       11 

Tubercular  ascites  ...         ...   (13)       ...       11  ...         2 

Xon- tubercular  ascites       ...  (20)       ...         0  ...       20 

In  cases  of  tubercular  meningitis  the  result  was  always 
negative  in  children,  but  two  adults  gave  positive  reactions. 
The  above  figures  would  suggest  that  the  test  may  be  a 
valuable  aid  in  the  diagnosis  of  tubercular  peritonitis  from 
conditions  which  produce  similar  symptoms,  such  as  cir- 
rhosis of  the  liver  and  chronic  simple  peritonitis,  if  the 
latter  condition  really  exist.  The  failure  of  the  reaction  in 
12  per  cent,  of  clinically  tuberculous  cases  suggests  that  for 
ordinary  use  the  test  is  of  doubtful  value.  The  non-appear- 
ance of  the  reaction  in  cases  of  tubercular  meningitis  in 
children  is  particularly  unfortunate,  as  this  disease  is  a  very 
insidious  one,  for  which  a  sure  test  would  be  of  the  greatest 
service,  while  it  would  certainly  not  be  legitimate  to  make 
use  of  tuberculin  in  such  a  malady. 

The  results  obtained  by  Beck  and  Rabinovitch1  were 
very  much  less  favourable  for  the  value  of  the  test.  Thus,  in 
cattle,  among  19  healthy  beasts,  12  gave  a  positive  reaction, 
and  among  4  suffering  from  diseases  other  than  tubercu- 
losis, 3  reacted.  Among  17  beasts  with  early  tubercle,  G 
were  negative,  and  among  22  moderately  advanced  caaefl 
2  were  negative  and  G  only  reacted  in  a  dilution  of  1  :  5, 
at  which  point  the  serum  of  even  healthy  cattle  may 
cause  agglutination.  Among  1G  very  advanced  cases,  1  was 
negative  and  4  reacted  only  at  1  :  o.  Tn  human  beings 
1  Quoted  by  Loeb,  loc.  rit. 


COMPLEMENT-FIXATION  295 

these  observer.}  record  that  among  17  cases  of  incipient 
tuberculosis  only  6  gave  a  positive  reaction,  and  among 
16  advanced  cases  only  4  reacted.  Among  5  doubtful  cases 
which  gave  a  positive  reaction  with  tuberculin  only  1 
reacted  positively  with  the  agglutination  test.  On  the  other 
hand,  of  31  non-tuberculous  cases,  10  reacted  positively. 

Humbert *  found  the  reaction  positive  in  4  cases  of 
miliary  tuberculosis,  and  thinks  the  test  useful  ;  as  do 
also  Sabareanu  and  Salomon,-  Vasilescu3  (diagnosis  from 
enteric  fever,  influenza),  and  Grysez  and  Job.4  Fried- 
mann  5  and  Kington  and  Twichell,6  however,  find  it  of  no 
value.  Simoni 7  found  it  of  use  in  the  diagnosis  of  tuber- 
cular ear-disease,  and  Pellegrini,8  who  admits  that  it  is 
uncertain,  in  surgical  tuberculosis. 

On  the  whole,  it  seems  necessary  to  conclude,  on  the 
evidence  at  present  available,  that  the  agglutination  test  is 
of  little  or  no  practical  use  in  the  diagnosis  of  tuberculosis. 
This  is  the  opinion  of  Koch  and  of  Beck  and  Rabinovitch, 
The  margin  of  error  is  too  great  for  the  test  to  afford  trust- 
worthy indications  for  clinical  use.  The  most  hopeful  field 
for  further  experiments  with  this  reaction  is  in  the  diagnosis 
of  tubercular  ascitic  effusions,  in  which  the  fluid  is  easily 
obtained,  and  in  which,  so  far,  the  recorded  results  are 
encouraging. 

Complement-fixation.— The  application  of  this  reaction 
as  a  test  for  the  presence  of  tuberculosis  has  been  the  subject 
of  many  observations  recently,  various  antigens  being  tried 
by  different  experimenters,  such  as  Old  and  New  Tuber- 
culin, defatted  tubercle  bacilli  (Momose),  and  extracts  of 
tuberculous  organs  (Hammer).  Early  observations  were 

1  Rev.  de  la  Tubcrc.,  1904,  p.  233. 

"  Rev.  do  Med.,  1905,  No.  7. 

3  Tnaug.  Diss.  Bucharest,  1905. 

<  Rev.  de  Med.,  1906,  p.  705. 

5  Abstr.  in  Centralbl.  f.  inn.  Med.,  1906,  p.  757 

(i  Amcr.  Journ.  Med.  Sci.,  Oct.,  1906. 

7  Gaz.  degli  Ospedali,  May  1,  1904. 

8  la  dm.  Mod,,  1904,  x.,  Nos.  27,  28. 


SKHTMS,    VACCINES,    AND    TOXINS 

made  by  Citron  and  by  Nesfield.  Wwedeiisky,1  who  tried 
the  reaction  in  cases  of  surgical  tuberculosis,  found  that 
it  was  not  of  much  use  in  the  diagnosis  of  early  cases,  and 
might  fail  in  cases  which  were  clinically  obvious  ;  as  a  rule. 
early  active  tubercle  and  miliary  infection  gave  positive 
results,  while  old  chronic  cases  were  frequently  negative. 
Probably  surgical  (localized)  cases  are  less  favourable  for  the 
formation  of  antibodies  than  those  of  pulmonary  disease,  in 
which  absorption  of  toxins  is  theoretically  more  constant 
and  considerable. 

Dudgeon,  Meek  and  Weir,  -  who  used  rubbed-up  bacilli 
as  antigen,  found  a  positive  reaction  in  86  of  100  clini- 
cally tuberculous  patients  who  had  not  been  treated  with 
tuberculin,  After  such  treatment  a  positive  reaction  was 
invariably  obtained. 

Besredka3  prepared  a  special  antigen  by  cultivating 
separately  human  and  bovine  bacilli  on  a  medium  consisting 
of  5  parts  broth,  4  of  albumin,  and  1  of  yolk  of  egg  (or 
alternatively  10  parts  broth  and  0'5  part  egg-albumin)  for 
thirty  days.  The  cultures  are  sterilized  and  mixed.  Working 
with  other  helpers,  he  found  that  in  guineapigs  the  reaction 
becomes  positive  four  days  after  infection  when  there  are 
no  visible  anatomical  lesions  ;  it  disappears  as  the  disease 
spreads,  but  afterwards  reappears  when  the  infection  is 
widespread,  and  persists  till  shortly  before  the  death  of  the 
animal.  In  rabbits,  the  reaction  is  strongest  in  animals 
which  have  considerable  resistance  to  the  bacilli.  In  man, 
out  of  750  persons  taken  at  random,  665  were  negative,  16 
doubtful,  and  69  positive.  Of  these  last,  53  were  clinically 
tuberculous.  Of  107  definitely  tuberculous  patients,  all  in 
the  early  stage  gave  positive  reactions,  and  most  of  those  in 
the  middle  period  of  the  disease.  Advanced  cases  reacted 


Vratch,  1913.  p.  1540;  abstr.  in  Zeiit.  f.  Immunitdti- 
forsch..  Ref.,  1913,  p.  931. 

-  Lancet,  1913.  i.  19. 

3  Con.pt.  Rend.  Acad.  Sciences.  1913,  p.  1633  ;  abstr.  in  Zeits.  f. 
Immunitatsforsch.,  I.  Theil.  1914,  xxi.  77. 


COMPLEMENT-FIXATION 


297 


irregularly,  some  giving  positive,  others  negative  reactions. 
Of  43  clinically  non- tuberculous  patients,  all  gave  a  negative 
reaction.  Intnan,1  working  at  Brompton  Hospital  with 
Besredka's  antigen,  found  that  out  of  a  first  series  of  52 
tuberculous  patients,  50  gave  a  positive  reaction,  2  a 
negative.  In  a  series  of  107  cases  which  we  had  the 
opportunity  of  observing  clinically  the  results  were  as 
follow  : — 


Clinical  diagnosis 

No.  of 
cases 

Complement-fixation  test 

Positive 

Negative 

Clinically  tuberculous  .     .     . 
Clinically  doubtful  

70 
11 
22 
2 
2 

•;:  (95-6%) 

4 
4  doubtful 
2 
1  doubtful 

3 

7 
18  (81-8  %) 

1 

Clinically  non-tuberculous     .     . 
Tuberculosis,  not  pulmonary 
Apical  fibrosis  in  children      .     . 

Total           .          ... 

107 

78 

29 

Much  less    satisfactory  results  were    obtained  with  an 
antigen  prepared  in  the  hospital  laboratory. 

Marmorek  2   devised    a    complement-fixation   technique 

carried  out  with  his  antitubercular  serum  and  with  either 

t 

the  serum  or  the  urine  of  tuberculous  patients.  The 
procedure  consists  in  mixing  0'2  c.c.  of  the  patient's  serum 
or  a  similar  amount  of  urine  with  0'3  c.c.  of  Marmorek's 
serum  and  0'5  c.c.  of  fresh  guineapig's  serum  (complement), 
and  incubating  for  one  hour.  Sensitized  erythrocytes  are 
then  added,  and  the  mixture  again  incubated  for  three- 
quarters  of  an  hour.  If  there  is  no  haemolysis,  the  reaction 
is  positive.  Marmorek,  who  tested  306  specimens  of  serum 
and  294  of  urine,  found  that  in  only  28  cases  (5  per  cent.) 
did  the  test  fail  to  correspond  with  the  clinical  diagnosis. 
Bergeron3  found  that  of  72  cases  of  febrile  tuberculosis 

1  Lancet,  1914,  i.  1446.  j 

2  Presse  Med.,  1909.  No.  |2. 

3  Ibid.,  1910,  No.  1. 


298       SERUMS,    VACCINES,    AND    TOXINS 

63  reacted  strongly  (no  haemolysis)  and  7  weakly  (partial 
haemolysis),  while  2  were  doubtful  (traces  of  haemolysis). 
Of  14  cases  of  tuberculosis  of  the  serous  membranes,  7 
reacted  strongly  and  7  weakly.  In  slight  or  apyrexial 
tuberculosis  the  results  were  not  good,  only  23  cases  out  of 
42  giving  a  positive  reaction.  Klinkert  '  holds  that  the 
reaction  is  not  sufficiently  specific  to  be  of  service  in 
diagnosis. 

Mclntosh,  Fildes  and  Radcliffe,2  using  a  suspension  of 
tubercle  bacilli  in  saline  fluid  as  antigen,  record  the 
following  results  : — 

Cages         Positive      Xfyaiive 

(a)  Pathologically  certain  tuberculosis — 

Pulmonary             43  33  (76'7  %)  10 

Surgical      26  21(80-7%)  ft 

Glandular 16  6  (37  5  %)  10 

(b)  Clinically  certain  tuberculosis  — 

Pulmonary  or  pleural       18  10(55-5%)  8 

Surgical      42  30  (71-4  %)  12 

(c)  Doubtful  tuberculosis  (various)        ...  74  18(24-4%)  56 

(d)  Controls           87  3»  (3-4  %)  84 

They  conclude  that  a  positive  reaction  definitely  indicates 
active  tuberculosis,  and  that  the  test  is  thus  more  valuable 
than  the  cutaneous  tuberculin  test  of  von  Pirquet. 

Precipitation  test. — Porter  '  described  a  precipitation 
test  for  tuberculosis  which  is  carried  out  as  follows:  To 
1  c.c.  of  B.E.  are  added  19  c.c.  of  sterile  distilled  water,  and 
the  mixture  is  kept  at  37°  C.  for  twenty-four  hours.  It  is 
then  divided  into  two  portions  :  to  one  (A)  is  added  water 
up  to  25  c.c.,  with  enough  sodium  chloride  to  make  the  whole 
isotonic ;  to  the  other  (B),  the  same  fluid  with  the  addition 
of  phenol  to  make  0*5  per  cent.  These  mixtures  are  kept  for 

1  Zeitsclir.f.  exper.  Pathol..  I'.Hl.  viii.  4-".l. 
-  Lancet,  1914,  ii.  4S.'>. 

3  Two  cases  of  leprosy  and  one  of  Addisoa's  disease.     The  serum 
in  18  syphilitic  cases  was  uniformly  negative. 

4  Journ.  Infect.  Dis.,  1!»U>.  vii.  Xo.  0. 


DIAGNOSTIC    USE    OF    TUBERCULIN      299 

twelve  hours  at  37°  C.  and  then  filtered  through  porcelain. 
The  serum  to  be  tested  is  diluted  to  1  : 20  with  0'5  per  cent, 
saline  solution,  and  divided  into  three  tubes.  To  one  is 
added  an  equal  quantity  of  solution  (A),  to  a  second  the 
same  amount  of  solution  (B),  and  to  the  third  the  same 
amount  of  phenolized  (0'5  per  cent.)  saline  solution.  These 
mixtures  are  incubated  at  37  °  C.  for  twenty-four  hours,  and 
then  examined  for  the  formation  of  a  precipitate,  the  last- 
named  mixture  being  the  control.  Porter  finds  40  per  cent,  of 
early  cases,  62  per  cent,  of  chronic  cases,  and  20  per  cent, 
of  advanced  and  acute  cases  positive,  against  about  12  per 
cent,  positive  in  non-tuberculous  cases.  The  method  does 
not  seem  to  be  of  much  value  as  a  means  of  diagnosis, 

DIAGNOSTIC   USE  OF  TUBERCULIN 

Veterinary  use. — As  a  means  of  recognizing  the  presence 
of  tuberculosis,  tuberculin  has  proved  of  the  greatest  ser- 
vice, especially  in  veterinary  practice.  It  is  of  considerable 
importance  to  be  able  to  discover  the  existence  of  the 
disease  in  herds  of  cattle;  and  by  injecting  the  animals 
with  Koch's  prepai'ation  the  diagnosis  can  be  made  with 
almost  entire  certainty,  even  in  the  absence  of  any  symp 
toms  of  the  malady.  The  injection  does  no  harm  to  the 
beasts  beyond  the  temporary  febrile  symptoms  which  it 
produces  in  those  which  are  tuberculous.  No  effects  at  all 
are  produced  in  healthy  animals.  Thus  McEachran1  records 
the  use  of  tuberculin  in  22,023  cases  in  cattle  without  any 
ill  effects. 

Employment  in  man. — In  mankind  the  use  of  tuber- 
culin as  a  diagnostic  agent  has  been  much  debated.  It 
must  be  remembered  that  the  results  of  careful  post-mortem 
examinations  have  proved  that  tubercular  infection  is  very 
widely  spread  among  all  classes  of  the  population,  so  that 
some  80  per  cent,  of  all  persons  who  reach  the  age  of  40 
probably  have  healed  tuberculous  lesions  in  some  part  of 
the  body,  this  percentage  falling  in  lower  age-groups,  but 
1  T?ans.  Brit.  Congr.  of  Tuber c.,  iv.  114, 


300       SERUMS,    VACCINES,    AND   TOXINS 

being  still  very  considerable  in  all  individuals  above  5  or  6 
years  of  age.  Infected  persons,  who  have  overcome  the 
infection  and  are  apparently  quite  healthy,  may  yet  give 
a  positive  reaction  to  tuberculin.  Hence  the  value  of  any 
form  of  tuberculin  test  is  greatest  in  children  and  diminishes 
in  value  with  advance  in  age. 

Where  a  hypodermic  injection  of  tuberculin  is  ad- 
ministered for  diagnostic  purposes,  two  phenomena  are  of 
importance  besides  the  rise  of  temperature  and  constitu- 
tional disturbance  that  follow  in  tubei'culous  subjects. 
There  is  in  such  persons  often  considerable  local  reaction  at 
the  seat  of  infection,  in  the  form  of  redness  and  oadema, 
which  may  appear  apart  from  febrile  disturbance  and  yet 
point  to  some  tubercular  infection,  probably  of  an  inactive 
kind  if  the  local  effects  alone  are  observed.  There  is  also 
in  some  cases  a.  focal  reaction  at  the  seat  of  the  tuberculous 
lesion  which  is  of  particular  importance  as  indicating  the 
seat  of  the  tuberculous  lesion.  Thus  in  a  consumptive 
person  fresh  physical  signs  (rales)  may  appear  in  the  chest 
as  the  result  of  an  injection  of  tuberculin,  definitely  point- 
ing to  the  lungs  as  the  seat  of  disease;  in  cases  of 
tuberculous  joints  there  may  be  pain  and  signs  of  fresh 
arthritis ;  in  genito-urinary  tuberculosis,  haeniaturia  :  and 
so  forth.  In  pulmonary  cases  this  local  exacerbation 
may  lead  to  the  appearance  of  tubercle  bacilli  in  the 
sputum,  which  should  be  examined  afresh  after  giving  an 
injection. 

That  tuberculin  is  of  service  diagnostically  cannot  ]>e 
denied,  but  it  has  been  held  that  there  are  draicbacks 
which  counterbalance  its  usefulness. 

(1)  It  is  urged  that  in  a  certain  proportion  of  cases  the 
injection  of  tuberculin  may  light  up  again  an  infection 
which  has  become  quiescent,  and  may  thus  cause  an 
exacerbation  of  the  disease.  It  is  very  difficult  to  make 
certain  of  the  facts  in  this  respect,  since  tuberculosis  is  a 
disease  which  is  very  liable  to  sudden  exacerbations  without 
the  administration  of  any  drug,  and  it  is  probable  that 


DIAGNOSTIC    USE    OF    TUBERCULIN      301 

many  of  the  ill  effects  attributed  to  the  action  of  tuberculin 
have  been  only  accidental  concomitants. 

Koch,  writing  in  1897,  remarked:  "The  most  valuable 
property  of  tuberculin  is  that,  even  when  injected  sub- 
cutaneously  in  very  minute  doses,  it  gives  rise  to  the  char- 
acteristic reaction  in  both  men  and  animals  affected  with 
tuberculosis.  The  value  of  tuberculin  as  a  diagnostic 
agent,  on  which  I  laid  stress  in  my  first  publication  on 
tuberculin,  has  been  more  and  more  fully  vindicated  with 
the  lapse  of  time.  The  fear  that  along  with  the  reaction 
tubercle  bacilli  might  be  set  free  and  gain  a  footing  in 
healthy  parts  of  the  body  has  been  proved  to  be  unfounded 
in  many  thousands  of  injections  into  cattle  made  for  the 
purpose  mentioned.  In  not  one  single  case  was  it  possible 
to  detect  any  indication  of  such  unfettering  of  the  bacilli. 
In  view  of  this  evidence  the  foolish  prejudice  resting  on  the 
supposed  setting-free  of  the  bacilli  should  be  abandoned,  and 
use  should  be  made  of  the  diagnostic  properties  of  tuberculin." 
At  the  British  Congress  of  Tuberculosis,  Koch  quoted  3,000 
tests  made  with  tuberculin  in  man  .without  any  ill  effects; 
and  Anders  l  alludes  to  3,638  similar  injections  which 
were  equally  harmless.  On  the  other  hand,  Munzer  -  and 
Behring  3  regard  the  injections  as  distinctly  dangerous  ; 
and  we  believe  that,  if  large  doses  are  given,  there  is  solid 
ground  for  such  fears. 

(2)  There  is  some  danger  of  actually  inoculating  living 
and  virulent  tubercle  bacilli  in  the  tuberculin.     This  can 
hardly    be    the    case  with    the    old    tuberculin,  which    is 
generally  used  for  diagnostic    purposes  ;    but  in    the   new 
tuberculin    Thellung4  found  virulent  bacilli,   and  actually 
produced  infection  in  rabbits  and  guineapigs. 

(3)  The  test,  cannot  be  used  in  cases  in  which  the  patient's 

1  Trans.  Amer'.  Climatol.  Assoc.,  1900. 

3  Frag.  med.  Woch.,  1903,  March,  No.  13,  p.  145. 

3  Gesellsch.f.  inn.  Med,  Wien.,  March  12,  1903. 

4  Deut.  med.  Woch.,  1901,  No.  48  ;  and  Centralbl.  f.  Bakt.,  I.  Orig. 
1902,  xxxii.   28. 


.'LLtfclf   O 


302       SERUMS,    VACCINES,    AND    TOXINS 

temperature  rises  (apart  from  the  use  of  tuberculin)  to  as 
high  a  point  as  100°  F.,  because  in  such  instances  it  is  not 
possible  to  make  sure  of  the  reaction.  It  is  also  apparently 
unwise  to  use  the  drug  in  febrile  cases,  as  they  may  be 
injuriously  affected  by  it. 

(4)  Most  important  of  all  as  a  drawback  to  the  use  of 
the  test  for  diagnosis  is  the  fact,  now  ascertained,  that  the 
reaction  is  obtained  not  only  in  cases  of  active  tuberculosis, 
but  also  in  old  quiescent  cases  (and  it  is  in  these  that  there 
appears  to  be  some  danger  of  lighting  up  the  disease  afresh), 
and  in  some  persons  suffering  from  entirely  different  com- 
plaints. It  has  certainly  been  demonstrated  that  the  test 
is  not  so  absolutely  infallible  as  was  at  first  expected.  Thus 
Madison1  finds  that  there  may  be  marked  reaction  to  tuber- 
culin in  cases  in  which,  post  mortem,  no  sign  of  tuberculosis 
can  be  found.  He  also  quotes  cases  of  healed  tubercle  which 
gave  a  reaction  with  the  test ;  while  he  has  met  with  patients 
suffering  from  undoubted  tuberculosis  who  were  unaffected 
by  the  injections.  He  places  the  margin  of  error  at  10  per 
cent.  K.  Franz 2  (who  considers  that  there  is  no  danger 
in  the  injections)  found  that  the  presence  of  a  reaction 
in  healthy  persons  was  very  rare,  but  that  in  those  who 
are  out  of  health,  especially  in  individuals  who  are  the 
subjects  of  syphilis,  a  reaction  to  tuberculin  is  liable  to 
occur.  He  made  experiments  on  a  number  of  recruits, 
and  considers  that  on  the  whole  the  test  is  useful  and 
reliable. 

At  the  London  Congress  of  Tuberculosis,  E.  France 
related  the  results  which  he  obtained  upon  a  number  of 
insane  patients.  Out  of  55  persons  tested  he  found  that  45 
reacted  to  tuberculin.  Twenty-nine  of  the  latter  died,  and 
were  submitted  to  necropsy.  All  of  these  29  were  proved 
to  be  suffering  from  tuberculosis  at  the  time  of  death. 
Among  those  who  did  not  react  to  the  injections  5  died, 
and  were  examined  after  death ;  none  of  these  were  found 

1  Amer.  Med.,  Dec.  20,  1902. 
!  |  ±\Wient  med.  Woch.,  1902,  Nos.  36-38. 


DIAGNOSTIC    USE    OF    TUBERCULIN      303 

to  be  tuberculous.  These  results  are  very  favourable  to  the 
use  of  tuberculin. 

Koch  himself  claimed  99  per  cent,  of  correct  results  from 
the  use  of  the  test.  This  can  hardly  be  maintained  in  view 
of  the  results  of  other  observers,  unless  we  ascribe  special 
skill  to  the  inventor  of  the  test.  Probably  the  estimate  of 
10  per  cent,  of  error  is  not  far  wrong. 

The  result  of  a  test  with  tuberculin  may  be  inconclusive" 
in  individual  cases  in  which  the  question  of  the  tubercular  or1 
non-tubercular  nature  of  a  particular  lesion  is  at  issue. 
As  an  instance  the  following  case  may  be  quoted  :  The 
present  writers  administered  O'Ol  c.c.  to  a  weakly  child 
of  5,  weighing  only  1^  stone,  who  was  suffering  from 
enlarged  joints— with  a  view  to  determine  the  nature  of 
this  trouble.  A  reaction  ensued,  consisting  in  a  rise  of 
temperature  (which  had  previously  been  normal)  to  103°  F., 
with  rather  troublesome  vomiting.  The  little  patient  did 
not  seem  to  feel  ill,  but  complained  a  good  deal  of  the 
sickness,  as  she  could  not  keep  her  food  down  although  she 
felt  hungry.  No  ill  effects  ensued,  beyond  a  slight  degree  of 
redness  and  induration  at  .the  point  of  injection,  which 
appeared  about  the  third  day,  and  passed  off  by  the  fifth  or 
sixth.  The  temperature  fell  by  lysis,  rising  on  the  evenings 
of  the  three  ensuing  days,  but  each  time  to  a  lower  figure 
than  on  the  previous  night.  No  signs  of  redness  or  swelling 
were  seen  in  the  neighbourhood  of  the  joints,  as  should 
have  occurred  had  the  lesions  been  tubercular  :  yet  the 
febrile  reaction  had  been  marked.  This  may,  however, 
have  been  due  to  some  small  focus  of  tuberculosis  in  the 
lungs  or  elsewhere. 

Tinker  l  states  that  if  the  dose  be  large  enough,  even 
healthy  persons t  react.  He  also  points  out  that  different 
specimens  of  tuberculin  vary  much  in  strength,  and  that  a 
source  of  error  thus  arises  in  comparing  results  obtained.  He 
lays  stress  on  the  advisability  of  beginning  with  small  doses. 

In  view  of  the  unpleasantness  of  the  results  of  the 
1  Johns  Hopkins  Hosp.  Kepis.,  1903,  xi.  544. 


304       SERUMS,    VACCINES,    AND    TOXINS 

injections  (fever,  vomiting,  etc.)  in  many  patients,  as  well 
as  the  possibility  of  exciting  an  exacerbation  of  the  disease 
— however  remote  this  possibility  may  be — we  should 
refrain  from  making  use  of  this  means  of  diagnosis  unless 
there  exist  special  reasons  for  its  employment. 

Definite  contraindications  to  the  use  of  diagnostic 
doses  are  the  existence  of  fever,  nephritis,  haemoptysis,  and 
cardiac  failure.  Epilepsy  is  also  considered  by  Bandelier 
and  Roepke  l  to  constitute  a  sufficient  danger  to  make  the 
procedure  unadvisable,  as  are  also  diabetes,  arterio-sclerosis, 
and  amyloid  change.  It  should  not  be  used  upon  very  de- 
bilitated persons  or  during  menstruation  ;  while  in  hysteri- 
cal patients  a  rise  of  temperature  after  an  injection  is  not 
of  the  same  diagnostic  import  as  in  less  emotional  subjects. 
Used  with  these  limitations,  and  with  due  regard  to  the 
margin  of  error  alluded  to,  there  can  be  no  doubt  that 
we  have  in  tuberculin  a  valuable  assistance  in  the  diagnosis 
of  eai'ly  or  obscure  cases  of  tuberculosis. 

Mode  of  using  tuberculin  for  diagnostic  pur- 
poses.— Old  tuberculin  is  generally  supplied  in  small  glass 
bottles  containing  1  c.c.  For  use  it  must  be  diluted  with 
a  25-per-cent.  solution  of  glycerin,  if  small  doses  are  needed. 
Thus,  to  administer  O01  c.c.  the  quantity  contained  in  the 
original  bottle  may  be  diluted  with  9  c.c.  of  glycerin  solu- 
tion, and  ^  c.c.  of  the  resulting  fluid  given  hypodermically. 
The  position  for  the  injection  is  immaterial.  Slight  red- 
ness and  wdema  may  occur  at  the  point  of  injection,  but 
this  passes  off  without  any  ill  effects. 

The  advice  given  by  Koch  for  the  diagnostic  use  of 
tuberculin  is  as  follows :  It  is  necessary  to  observe  the 
course  of  the  patient's  temperature  carefully  for  a  day  or 
two — preferably  two — before  the  injection  is  given,  in  order 
to  make  sure  that  the  daily  excursion  is  within  moderate 
limits.  A  temperature  of  100°  F.  is  a  contraindication 
to  the  use  of  tuberculin,  as  not  only  does  the  existence 

1  "  Lehrb.  der  spec.  Diagnostik  u.  Therap.  der  Tnberk."  Wurz- 
burg,  1908. 


DIAGNOSTIC    USE    OF    TUBERCULIN      305 

of  such  a  degree  of  fever  render  it  difficult  to  ascertain 
the  exact  effect  produced  by  the  injection,  but  the  condition 
of  such  febrile  cases  is  sometimes  depressed  by  the  remedy. 
If  the  patient  is  suitable  in  the  above  respect,  it  is  neces- 
sary to  take  into  account  also  his  general  state  of  strength 
or  weakness,  in  order  that  the  dose  of  tuberculin  may  be 
modified  accordingly.  Delicate  individuals  receive  for  a 
first  injection  O0001  c.c.,  whereas  those  who  appear  to 
be  in  fair  health  may  at  once  receive  O'OOl  c.c.  The 
injection  is  given  beneath  the  skin  of  the  back  between 
the  scapulae.  The  reaction  may  be  expected  in  about 
twelve  hours,  and  Koch  prefers  to  give  the  injection  in 
the  afternoon.  If  no  reaction  takes  place,  a  second  dose  of 
double  the  quantity  first  administered  is  given  on  the  third 
day  ;  while  if  a  very  slight  reaction,  such  as  a  rise  of  half 
a  degree,  occurs,  the  same  dose  as  that  which  produced  this 
effect  is  repeated.  A  much  more  marked  rise  of  tempera- 
ture is  often  seen  after  this  procedure.  Koch  regards  this 
phenomenon  (increased  reaction  on  repetition  of  a  small 
dose)  as  very  characteristic  of  tuberculosis.  If,  however, 
no  effect  is  produced  by  the  small  doses,  they  may  be 
increased  to  0-005  and  even  to  0-01  c.c. ;  and  this  final 
dose  may  be  administered  twice  in  order  to  make  sure  of 
the  absence  of  a  reaction. 

Junker l  advises  the  following  doses  for  diagnostic  pur- 
poses: 0-0001,  0-0005,  O'OOl,  0005,and  0-01  c.c.  Lowenstein 
and  Kaufmann2  give  4  doses  of  0-0002  c.c.,  and  if  there  is  no 
reaction  continue  with  0*002,  0'005,  and  0-01  c.c.  Roepke3 
finds  this  repetition  of  0-0002  c.c.  insufficient  in  many  cases  ; 
he  advises  successive  doses  of  0-0002,  0-001,  and  0-005  c.c. 

In  the  case  of  children,  Escherich  gives  0-0002  to  0-0005 
c.c.  to  younger,  and  0-0005  to  O'OOl  c.c.  to  older  patients  ; 
Beck  gives  0-0005  c.c.  to  all  under  10  years;  Leser  gives 
children  ±  to  |,  and  Heubner  ^  of  the  adult  dose  ;  Epstein 

1  Beitr.  z.  Klin,  der  Tuberk.,  Bd.  vi.,  Heft  4. 

2  Zeitschr.f.  Tuberk.,  1907,  Bd.  x.  17. 

3  Ibid.,  1907,x.  o. 


306       SERUMS,    VACCINES,    AXD    TOXINS 

gives  children  under  3  years  0*0001  c.c.,  and  gradually  raises 
the  dose  by  small  increments  to  0-0005  c.c.1 

Trudeau  gives  the  injection  as  late  at  night  as  possible, 
so  as  to  bring  the  reaction  to  a  convenient  time  of  day. 
He  insists  on  the  importance  of  using  a  fresh  tuberculin 
solution,  which  he  prepares  with  i-per-cent.  carbolic-acid 
solution  ;  it  must  not  be  more  than  three  days  old.  He 
starts  with  a  dose  of  0  001  c.c.,  and,  if  this  produces  no  re- 
action, goes  on  to  doses  of  0-003  c.c.  and  then  to  0-005 
and  0-007.  M.  Beck  begins  with  a  dose  of  0-001  c.c.  even  in 
weakly  persons.  In  children  under  5  years  of  age  he  starts 
with  0'0003  c.c.,  and  goes  on  to  a  second  dose  of  0-001  c.c., 
and  then  to  one  of  0-005  c.c.  In  children  between  5  and  10 
he  starts  with  O'OOOS  c.c.,  and  gives  O'OOo  as  the  maximum 
tiose. 

One-thousandth  of  a  cubic  centimetre  is  probabfy  the 
largest  dose  which  s/iould  ever  be  administered  for  diagnosis. 
The  authors  consider  that  doses  of  O'OOOl  c.c.,  0'0002  c.c., 
0*0005  c.c ,  0*001  c.c.,  form  the  most  suitable  series. 

Conclusions  as  to  the  diagnostic  use  of  tuber 

CUlin.— Taking  all  the  evidence  at  present  available,  the 
conclusion  appears  to  be  that  there  is  a  certain  degree  of 
danger  in  administering  a  diagnostic  injection  of  tuber- 
culin, but  probably  not  more  than  in  giving  an  anjesthetic 
for  similar  purposes.  In  no  case  should  we  adopt  either 
means  if  it  is  possible  to  make  a  diagnosis  otherwise  ; 
but  if  the  matter  is  one  of  urgency  we  should  not 
hesitate  to  make  use  of  the  drug.  In  doubtful  cases 
of  phthisis,  careful  physical  examination  should  be  first 
made,  and  the  sputum  should  be  examined  for  tubercle 
bacilli.  If  these  methods  do  not  clear  up  the  nature  of 
the  case,  >*/  must  consider,  from  the  point  of  view  of  the 
interests  of  the  patient,  whether  it  is  necessary  to  resort  to 
an  injection  of  tuberculin.  In  the  majority  of  instances 
probably  it  is  .»*  i.erable  to  wait,  the  patient  being  mean- 
while put  into  ihe  most  favourable  possible  circumstances 
1  Quoted  by  Schiek,  Jahrb.  f.  Kinderheillt.,  1905,  lii.  811. 


DIAGNOSTIC    USE    OF    TUBERCULIN      307 

to  combat  the  disease,  if  it  be  present.  Open-air  life  and 
plentiful  feeding  will  form  suitable  treatment  for  the 
majority  of  conditions  which  are  liable  to  be  confused  with 
tuberculosis.  But  there  are  a  certain  number  of  cases  in 
which  the  question  of  the  presence  or  absence  of  tubercle  is 
of  such  importance  that  any  means  of  reaching  certainty 
without  further  delay  should  be  adopted.  Such  an  instance 
might  be  seen  in  the  case  of  a  young  man  just  starting  in 
life,  who  had  to  decide  on  what  profession  or  course  of  life 
he  should  adopt.  It  might  be  a  question  whether  it  was 
right  for  him  to  enter  on  an  indoor  life  in  a  London  office, 
or  better  that  he  should  emigrate  and  lead  an  open-air 
existence  in  one  of  the  colonies.  Such  a  question  might 
need  an  immediate  answer,  and  an  injection  of  tuberculin 
might  here  be  not  only  permissible  but  advisable.  So,  too, 
might  it  be  in  the  case  of  a  young  woman  belonging  to  a 
tubercular  family,  who  had  perhaps  recently  suffered  from 
pleurisy,  and  who  sought  advice  as  to  the  propriety  of 
marrying.  But  such  cases  will  constitute  the  minority  of 
those  met  with  in  practice.  The  test  should  not  be  used 
indiscriminately,  merely  for  our  own  satisfaction.  The 
danger  run  may  be  minimal,  but  for  such  a  purpose  we 
have  no  right  to  run  any  danger  at  all.  It  is  not  justifiable 
to  begin  with  large  doses  of  the  di-ug. 

Special  modes  of  administering  tuberculin  for 

diagnosis, — Von  Pirquet1  has  suggested  the  inoculation 
of  tuberculin  into  the  skin  instead  of  hypodermic  injection. 
For  this  purpose  the  skin  is  cleaned  as  if  for  a  surgical 
operation ;  a  drop  of  tuberculin  is  placed  upon  it ;  and 
through  this  a  series  of  scratches  are  made  as  in  vaccination, 
or  preferably  a  circular  scarification  made  by  means  of  a 
special  "  Yon  Pirquet "  platinum  spud  with  three  sharp 
points.  A  "  control "  lesion  is  made  by  scratc  ig  with 
another  aseptic  needle  through  a  drop  of  sterile  saline 
solution  at  another  point.  In  tuberculous  si "  iects  this  pro- 
cedure is  followed  by  an  inflammatory  reaction  at  the  seat 
1  Deut.  med.  Woch.,  May  23,  1907. 


308       SERUMS,   VACCINES,    AND    TOXINS 

of  inoculation  with  the  tuberculin  (cutaneous  reaction) : 
this  varies  from  slight  redness  round  the  scratches,  to  an 
indurated  papule  and  even  a  vesicle  or  group  of  vesicles, 
which  may  subsequently  undergo  desquamation.  The  re- 
action usually  occurs  within  twenty-four  hours :  it  is 
occasionally  delayed,  and  may  be  at  its  maximum  on  the 
third  or  fourth  day.  A  certain  amount  of  pigmentation 
may  occur,  and  persist  for  several  weeks.  There  is  no 
danger  in  this  procedure,  but  its  value  as  a  test  for  the 
presence  of  tuberculosis  is  disputed. 

Ellermann  and  Erlandsen  *  modified  this  test  by  making 
four  separate  scarifications  each  through  a  drop  of  tuberculin 
varying  in  the  degree  of  dilution — the  strengths  recom- 
mended being  1  per  cent.,  4  per  cent.,  16  per  cent.,  and 

64  per  cent,  (quantitative  cutaneous  reaction).     In 

the  non-tuberculous  or  papular  form  they  are  all  more  or 
less  of  equal  size ;  in  the  tuberculous  the  size  of  the  papules 
increases  with  the  percentage  of  tuberculin  employed.  The 
scarifications  are  usually  made  on  the  forearm  in  its  long 
axis,  the  1-per-cent.  drop  being  deposited  nearest  the  hand, 
the  4-per-cent.  drop  about  an  inch  higher  up,  and  so 
on.  The  measurement  of  the  resulting  papules  is  carried 
out  twenty-four  and  forty-eight  hours  later,  when  the  sum 
of  the  average  diameters  is  utilized  to  obtain  an  average 
papule  size,  which,  together  with  the  figure  representing  the 
average  difference  between  successive  papules  (papule  dif- 
ference), is  applied  to  an  empirical  table  to  ascertain  the 
appropriate  figure,  which  is  termed  the  sensitiveness  value. 
The  authors  regard  100  as  the  crucial  figure  and  consider 
sensitiveness  values  above  this  as  indicating  active  tubercu- 
losis. In  this  modified  form  the  cutaneous  test  appears  to 
have  considerable  diagnostic  value. 

Moro  -  employs  inunction  of  old  tuberculin  worked  up 
with  an  equal  bulk  of  lanolin  to  produce  a  similar  reaction 

(percutaneous  reaction). 

1  Dent.  »ied.  Woeh.,  1909,  xxxv.  436. 

2  Munch,  med.  JToeh.,  1908,  xlv.  209. 


OPHTHALMIC    TUBERCULIN    TEST        309 

Calmette,  of  Lisle,  and  Wolff-Eisner,  of  Berlin,  indepen- 
dently suggested  the  instillation  of  tuberculin  into  the 
conjunctival  sac  as  a  test  for  the  presence  of  tuberculosis. 
The  procedure  is  generally  known  as  Calmette's  ophthal- 
mic reaction.  It  can  be  performed  with  a  solution  of  old 
tuberculin  (1-10  per  cent.,  Wolff-Eisner) ;  but  owing  to  the 
irritant  action  of  the  glycerin  contained  in  this  preparation, 
a  solution  of  the  precipitate  obtained  by  treating  tuberculin 
with  absolute  alcohol  is  generally  employed.  This  can  be 
obtained  commercially  in  a  form  suitable  for  making  the 
solutions.  A  drop  of  the  fluid  is  placed  in  the  hollow  formed 
by  drawing  down  the  lower  eyelid,  and  the  patient  is 
directed  to  hold  the  head  back  for  a  minute  or  so,  in  order- 
that  the  tuberculin  may  not  at  once  escape.  In  tuberculous 
subjects  an  inflammatory  reaction  ensues  within  twelve  to 
twenty-four  hours.  The  untreated  eye  serves  as  a  control 
for  comparison.  As  soon  as  the  reaction  has  been  observed, 
a  lotion  of  boric  acid  should  be  prescribed,  and  used  until 
the  inflammation  has  subsided. 

A  large  number  of  observations  have  now  been  made 
on  the  use  of  this  reaction  clinically.  Fortescue-Brickdale1 
collected  the  statistics  relating  to  over  4,000  .cases,  with 
the  following  results  :  Of  1,623  cases  clinically  tuberculous, 
1,419,  or  87'4  per  cent.,  gave  a  positive  reaction;  of  1,931 
clinically  non-tuberculous,  214,  or  ll'l  per  cent.,  were  posi- 
tive ;  and  of  710  which  were  doubtful,  275,  or  38-7  per  cent., 
gave  the  reaction.  From  this  it  would  seem  that  the  test 
is  of  considerable  value  as  a  means  of  recognizing  the 
existence  of  tuberculosis,  but  is  not  infallible.  Our  personal 
experience  bears  out  this  view,  and,  moreover,  suggests 
that  the  ophthalmo-reaction  is  more  reliable  than  other 
tuberculin  tests,  in  the  adult,  as  it  less  frequently  gives 
a  positive  result  in  cases  where  the  tuberculous  lesion  has 
satisfactorily  healed. 

On  the  other  hand,  it  must  be  admitted  that  the  pro- 
cedui'e  is  not  entirely  free  from  risk.  In  an  exceedingly 
1  Bristol  Med.-Chir.  Journ.,  1908,  xxvi.  112. 


310       SERUMS,    VACCTXES,    AND    TOXINS 

small  number  of  cases  a  severe  conjunctivitis  may  result, 
and  may  last  for  fourteen  days  or  more,  causing  the  patient 
considerable  inconvenience.  In  rare  instances  mechanical 
injury  to  the  conjunctiva  has  appeared  to  be  the  starting- 
point  of  phlyctenular  ulceration,1  and  in  one  case  an 
incised  wound  of  the  cornea  caused  by  the  point  of  the 
pipette  during  instillation  of  the  tuberculin  was  followed 
by  sloughing  of  the  cornea,  hypopion,  and  destruction  of  the 
globe.  Then,  too,  the  solution,  when  exposed  to  the  air,  is  an 
excellent  cultivation-medium  for  bacteria,  and  the  introduc- 
tion of  septic  material  into  the  conjunctival  sac  may  give 
rise  to  troublesome  symptoms.  Care  must  therefore  be 
taken  to  use  sterile  solutions.  Any  existing  disease  of  the 
eye  must  lie  held  an  absolute  bar  to  the  use  of  the  test,  as 
it  is  impossible  to  foresee  the  extent  of  the  inflammation 
that  will  ensue.  Wolff- Eisner,2  however,  does  not  regard 
conjunctivitis  as  a  contraindication  ;  and  Stephenson  3  even 
recommends  the  use  of  the  test  for  cases  of  suspected 
tubercular  disease  of  the  eye. 

On  the  whole,  we  are  inclined  to  consider  Calmette's 
test  as  of  great  value,  as  it  is  free  from  the  risk  of  causing 
severe  constitutional  disturbance  and  consequent  ill  effects 
on  the  tubercular  process  elsewhere,  and  the  danger  of 
causing  injury  to  the  eye  itself  is  exceedingly  small  when 
the  test  is  properly  applied. 

1  See  Butler,  Brit.  Jfed.  Jotirn.,  1908,  ii.  304. 

2  "The  Ophthalmic  and  Cutaneous  Diagnosis  of  Tuberculosis." 
Tr.  by  Robert,  1908. 

»  Brit,  Med.  Journ.,  190",  ii.  1038. 


CHAPTER    XVI 
TUBERCULOSIS  (Concluded) 

TREATMENT 
Nature  of  immunity  in   tuberculosis. — It  must  be 

confessed  that,  in  spite  of  the  wide  distribution  of  the 
disease,  we  have  little  definite  knowledge  as  to  the  mode 
of  resistance  on  the  part  of  the  host.  That  antibodies 
are  formed  is  certain,  as  is  shown  by  the  phenomena 
of  phagocytosis  and  opsonin-forniation,  of  precipitation, 
of  agglutination,  and  of  complement-fixation,  but  we  are 
ignorant  of  the  part  played  by  such  bodies  in  overcoming 
infection.  No  satisfactory  antitoxic  or  bactericidal  serum 
has  been  prepared.  For  purposes  of  specific  treatment 
three  forms  of  the  disease  may  be  distinguished  ; 

1.  Acute  generalized  tuberculosis. 

2.  Tuberculosis  of  the  lungs. 

3.  Localized  tuberculosis  of  other  organs,  collectively 

known  as  "  surgical  tuberculosis." 

1.  Acute  generalized  tuberculosis  is  an  acute  toxsemia, 
with  symptoms  closely  resembling  those  of  enteric  fever; 
it  indicates   an  almost  complete  lack   of  resistance  to  the 
bacilli,   and  is   met  with   in  children  and  young  persons. 
Theoretically,  an  antitoxic  serum  would  be  the  only  suitable 
remedy. 

2.  Tuberculosis   of    the   lungs   is   typically   a   chronic 
localized  infection,  affecting  organs  which  are  richly  supplied 
with  blood  and  which  cannot  be  kept  at  rest.    Consequently, 
except  in  the  most   chronic  cases,  in  which   the  disease  is 
shut  off  by  dense  fibrous  tissue,  there  is  likely  jbo  take  place 

311 


312       SERUMS,    VACCINES,    AND    TOXINS 

a  constant  escape  of  tuberculous  poisons  into  the  blood- 
stream (so-called  "  auto-intoxication  ").  Such  a  condition 
is  not  likely  to  be  benefited  by  vaccine  (tuberculin)  treat- 
ment, and  actually  there  is  little  evidence  in  favour  of  this 
procedure.  The  only  type  of  case  likely  to  receive  benefit 
from  such  treatment  is  the  localized  focus  with  surrounding 
fibrosis — the  apyrexial  chronic  consumptive. 

3.  Surgical  tuberculosis  is  analogous  to  other  localized 
infections,  such  as  furunculosis  or  urethritis,  and  might 
theoretically  be  expected  to  prove  suitable  for  vaccine 
treatment,  little  poison  spontaneously  reaching  the  general 
circulation,  and  little  formation  of  antibodies  being  con- 
sequently excited.  Inoculation  treatment  is  therefore 
theoretically  justiGable  in  this  form  of  the  disease,  and  in 
practice  it  is  found  that  treatment  with  tuberculin  is  often 
strikingly  successful. 

Therapeutic  use  of  tuberculin.— It   is  necessary 

to  bear  in  mind  that  tuberculin  of  any  kind  is  of  the  nature 
of  a  vaccine  and  not  of  an  antitoxin  ;  it  does  not  neutralize 
the  poisons  at  work,  nor  does  it  directly  kill  the  bacilli, 
but  acts  by  stimulating  the  body  to  the  formation  of 
antagonistic  substances.  Therefore  the  principles  already 
laid  down  as  to  the  employment  of  vaccines  apply  to  that  of 
tuberculin.  If,  on  the  one  hand,  large  doses  of  tubercular 
toxins  are  entering  the  patient's  circulation,  it  is  unreason- 
able and  can  only  do  harm  to  add  more  by  giving  tuber- 
culin in  any  form.  Now,  the  entrance  of  these  toxins  into 
the  system  is  to  be  inferred — since  they  cannot  be  directly 
identified — from  the  clinical  symptoms,  such  as  pyrexia, 
was-ting,  loss  of  strength,  and  so  forth.  It  is  therefore 
theoretically  inadvisable  to  use  such  a  remedy  in  pro- 
gressive, febrile  cases  of  tuberculosis,  wherever  the  disease 
is  situated.  Moreover,  the  production  of  antibodies  in 
response  to  the  tuberculin  depends  on  the  general  nutrition 
of  the  patient,  since  antibody-formation  is  to  some  extent 
analogous  to  secretion  and  depends  on  the  capacity  of  the 
tissue-cells  t«  assimilate  food-materials  and  build  up  the 


TUBERCULIN    IN    TREATMENT  313 

required  products.  Therefore  it  is  theoretically  unlikely 
that  an  emaciated  and  exhausted  patient  will  do  well  on 
tuberculin,  as  his  power  of  reaction  will  be  exhausted  ; 
while  it  is  necessary  to  carry  out  the  accepted  measures 
of  hygiene— plentiful  feeding  and  open-air  life — during  a 
course  of  tuberculin  in  order  to  increase  the  patient's 
reactive  capacity. 

There  can  be  little  doubt  that  the  disappointing,  often 
disastrous,  results  so  frequently  produced  by  the  use  of 
tuberculin,  when  it  was  first  introduced  to  the  medical 
world,  were  due  to  ignorance  of  the  nature  of  the  remedy 
and  of  the  effects  which  could  be  rightly  expected  of  it. 
Tuberculin  has  not — and  was  never  supposed  by  its  inventor 
to  have — any  power  of  replacing  tissue  already  destroyed 
by  the  disease  ;  nor  can  it  do  anything  to  check  the  action 
of  other  bacteria,  such  as  streptococci  or  staphylococci, 
which  may  have  secondarily  invaded  the  cavities  in  the 
lungs  or  other  ulcerated  lesions.  We  thus  see  that,  just 
as  in  serum  treatment  it  is  important  to  administer  the 
dose  of  antitoxin  before  the  poisons  of  the  bacteria  have 
gained  too  long  a  start  and  entered  into  combination  with 
the  cells,  so  it  is  equally  necessary,  if  permanent  cure  is 
to  be  effected,  to  make  use  of  tuberculin  (if  at  all)  in  the 
early  stages  of  tubercular  disease,  before  the  substance  of 
the  affected  organ  has  been  so  extensively  destroyed  as 
permanently  to  cripple  the  infected  individual  by  the 
loss  of  an  important  structure.  It  is  therefore  in  incipient 
tuberculosis  that  we  must  look  for  the  most  marked  results 
from  the  administration  of  tuberculin.  In  more  advanced 
cases  of  localized  disease  it  may,  indeed,  be  of  assistance  in 
increasing  the  resistance  of  the  body  to  the  tubercle  bacilli, 
but  permanent  .lesions  will  necessarily  remain,  and  no  cure 
in  the  truest  sense  can  be  hoped  for. 

A  further  reason  for  the  original  failure  of  tuberculin 
to  come  up  to  the  expectations  formed  of  it  was  that 
reliance  was  placed  upon  it,  alone  and  unaided,  to  ac- 
complish the  cure  of  tubercular  disease.  Its  value  is  now 


314       SERUMS,    VACCINES,    AND    TOXINS 

recognized  as  an  adjuvant  to  other  remedial  measures,  not 
as  a  specific  curative  agent,  such  as  is  mercury  fur  syphilis, 
or  quinine  for  malaria.  Used  rationally  in  the  light  of 
modern  experience,  tuberculin  is  now  proving  itself  a 
valuable  remedy  in  certain  forms  of  tuberculous  infection. 

By-effeCtS  Of  tuberculin. — The  injection  of  the  origi- 
nal tuberculin  (T.)  may  be  followed  by  the  appearance  of 
a  rigor  in  some  instances,  and  albumin  may  be  found  in 
the  urine.  Pains  in  the  joints  may  occur,  as  after  injec- 
tion of  serum.  In  some  cases  jaundice  has  resulted,  and 
affections  of  the  skin  may  be  produced.  Thus,  purpuric 
eruptions  have  been  recorded,  and  Thin  ]  quotes  an  instance 
in  which  a  generalized  scarlatinal  rash  appeared,  followed 
by  desquamation. 

The  new  tuberculin  (T.R.)  may  also  produce  rigors,  and 
severe  headache  may  occur  after  an  injection.  Albuminuria 
is  also  met  with,  and  may  be  considerable  in  amount.2 

Cranston  Low 3  records  the  appearance  of  a  rash  re- 
sembling lichen  scrofulosorum,  a  phenomenon  never  yet 
observed  by  the  authors.  Weischer  l  saw  an  acute  pleurisy 
arise  apparently  as  a  consequence  of  an  injection  of 
tuberculin,  and  we  have  more  than  once  seen  a  similar 
occurrence  as  the  result  of  too  large  a  dose. 

In  a  few  instances  death  has  followed  an  injection,  and 
has  been  attributed  to  the  action  of  the  tuberculin.5 

TUBERCULIN  IN  PULMONARY  TUBERCULOSIS 
The  question  of  the  value  of  tuberculin  in  the  treatment 
of  pulmonary  tuberculosis  is  one  of  the  greatest  importance 
at  the  present  time.  Owing,  to  some  extent,  to  recent  legisla- 
tion, "which  has  brought  the  care  and  control  of  consumptive 
persons  into  the  hands  of  the  State,  much  attention  has 

1  Brit.  Med.  Journ.,  1890,  ii.  1330. 

-'  Adrian,  Arch.  f.  Derm.  u.  Syp/i.,  1898,  Bd.  xlv.,  p.  97. 

3  Scott.  Med.  and  Surg.  Journ..  Sept.,  1905. 

4  Zeitschr.f.  Tuberk.,  1905,  Bd.  vii..  Hft.  3. 

5  See  Adler,  Frag.  med.  Jf'oeh.,  1904,  No.  30,  p.  389. 


TUBERCULIN    IN    CONSUMPTION         315 

been  concentrated  on  the  problems  presented  by  this  disease 
while  the  medical  supervision  of  these  patients  has  been 
entrusted  to  special  officers,  many  of  whom  have  not  pre- 
viously had  any  prolonged  experience  of  the  affection  with 
which  they  are  called  upon  to  deal.  As  a  result,  certain 
enthusiasts  for  the  use  of  tuberculin  have  been  able  to 
secure  for  their  views  a  large  and  uncritical  audience,  and 
the  belief  has  been  fostered  that  in  tuberculin  we  have  a 
remedy  which  is  applicable  to  a  large  percentage  of  all 
cases  of  consumption,  and  which  can  be  relied  upon  actu- 
ally to  cure  this  disease.  We  fear  that  very  grave  injury 
has  resulted  from  this  belief.  Owing,  perhaps,  to  the 
impossibility  of  keeping  the  lungs  at  rest,  and  to  the  free 
blood-supply  of  these  organs — conditions  which  favour  the 
free  passage  of  tubercular  poisons  into  the  patient's  circu- 
lation— pulmonary  tuberculosis  seems  to  stand,  with  respect 
to  treatment,  on  a  different  footing  from  the  localized  forms 
of  the  infection  met  with  in  bones,  joints,  and  glands,  and 
in  the  genito-urinary  tract.  Whatever  the  cause  may  be, 
the  number  of  cases  of  pulmonary  disease  in  which  good 
results  appear  to  follow  the  use  of  tuberculin  is  so  small 
that  it  is  difficult  to  be  sure  that  the  amount  of  good  done 
is  sufficient  to  counterbalance  the  dangers  that  are  in- 
herent in  the  method.  For  it  is  beyond  dispute  that  very 
great  harm  may  be  done  by  the  ill-judged  use  of  tuberculin 
in  consumptive  patients.  An  attack  of  pleurisy  and  an 
acute  exacerbation  of  the  disease  may  be  set  up  by  too 
large  a  dose,  and  the  progress  of  the  disease  may  be  accel- 
erated by  injudicious  injections.  Indeed  it  may  be  said  with 
some  degree  of  probability  that  the  discovery  of  tuberculin 
has  resulted  in  evil  rather  than  good  for  the  sufferers  from 
this  form  of  .tuberculosis.  In  any  event,  the  number  of 
cases  suitable  for  tuberculin  treatment  is  very  strictly 
limited.  If  tuberculin  is  to  be  used  at  all  in  the  treat- 
ment of  consumptives — and  it  would  be  far  preferable 
to  discard  it  altogether  than  to  admit  anything  approach 
ing  to  indiscriminate  use  of  so  dangerous  a  substance — it 


31G       SERUMS,    VACCINES,    AND   TOXTNS 

should  be  reserved  for  those  who  (1)  are  free  from  fever; 
2)  are  in  good  general  condition,  so  as  to  be  capable  of 
reacting  satisfactorily  in  the  direction  of  forming  antibodies; 
;vnd  (3)  are  not  making  progress  under  those  conditions  of 
fresh  air,  plentiful  diet,  and  regulated  life  which  constitute 
the  hygienic  treatment  of  the  disease. 

If  in  such  a  case  it  be  determined  to  try  tuberculin,  the 
initial  dose  must  be  exceedingly  small,  such  as  O'OOOOl  mg. 
T.R.  or  0-000005  mg.  B.E.,  the  patient  being  kept  in  bed 
and  watch  maintained  for  any  sign  of  reaction.  During 
the  course  of  injections  attention  must  be  paid  to  the  general 
condition  of  the  patient — weight,  appetite,  cough,  etc. — as 
well  as  to  the  temperature  chart.  Little  emphasis  can  be 
laid  on  his  subjective  sensations  following  the  injections. 
Whether  it  be  that  tuberculin  acts  as  a  temporary  stimulant, 
or  that  faith  in  an  occult  remedy  has  a  similar  effect,  con- 
sumptive persons  often  assert  that  they  are  deriving  marked 
benefit  from  these  injections  even  when  they  are  obviously 
declining  in  health.  As  an  instance  of  the  influence  of 
faith  in  this  connection  may  be  quoted  the  case  of  a  patient 
who  persisted  in  attributing  great  benefit  to  injections  of 
tuberculin  while  steadily  deteriorating  under  this  treatment. 
On  the  substitution  of  saline  solution,  without  his  know- 
ledge, for  the  tuberculin,  he  still  stated  that  he  felt  better 
after  each  administration  and  begged  for  a  continuance  of 
the  treatment. 

In  the  treatment  of  tubercular  disease  of  the  lung,  the 
original  tuberculin  has  obvious  drawbacks.  It  causes  re- 
action of  the  tissues  round  the  lesions,  and  consequent 
casting-off  of  diseased  material.  In  a  deeply  situated  organ 
such  as  the  lung,  the  cast-off  matter  cannot  be  readily 
expelled,  and  danger  may  ensue.  Hence  in  pulmonary 
disease  it  would  seem  preferable  to  employ  the  new  tuber- 
culin; but  both  varieties  have  been  used,  and  writers 
have  not  always  distinguished  between  them.  They  must 
therefore  be  considered  together. 

In  the  following  paragraphs  we  summarize  some  of  the 


TUBERCULIN    IN    CONSUMPTION         317 

more  noteworthy  views  which  have  been  published  on  this 
subject. 

In  a  communication  to  the  South  California  Medical 
Society,  in  1903,  Pottenger  l  gave  the  result  of  his  own 
experience  at  that  time,  along  with  much  information 
gained  in  answer  to  questions  addressed  to  some  of  the 
principal  authorities  on  the  treatment  of  tuberculosis  as 
to  their  experiences  with  this  remedy.  He  found  that 
of  those  who  had  actually  used  tuberculin,  60  per  cent, 
were  in  favour  of  it  as  a  means  of  treatment.  Those  who 
recommended  the  procedure  based  their  advice  on  as 
many  as  5,742  cases  treated,  whereas  those  who  were 
of  the  opposite  view  had  only  a  material  of  813  cases  to 
rely  upon ;  indeed,  only  four  of  those  who  denied  the 
value  of  the  drug  had  at  all  an  extensive  experience  of  its 
use.  This  is,  of  course,  only  what  might  be  expected,  as 
those  who  found  that  they  were  getting  no  good  results 
would  cease  using  the  tuberculin,  while  those  who  found  it 
of  value  would  persevere.  It  is  noteworthy  that  of  the  four  . 
who  had  tried  it  extensively,  and  yet  reported  unfavourably 
on  the  whole,  not  one  was  actually  opposed  to  its  use ;  and 
all  had  apparently  seen  some  cases  at  least  in  which  good 
had  been  done. 

In  the  majority  of  instances,  those  who  had  aban- 
doned tuberculin  treatment  had  not  at  any  time  given  it 
an  extended  trial ;  whereas  Petrushky  maintained  at  the 
Berlin  Congress  that,  in  order  to  produce  lasting  effects, 
the  treatment  should  extend  over  several  years,  a  course 
of  a  few  months  being  taken  each  year. 

Coming  to  actual  results  claimed  for  treatment  with 
tuberculin  in  addition  to  ordinary  measures,  we  find  that, 
in  addition  to,  his  own  success,  Pottenger  quotes  five  other 
physicians  who  claim  to  have  cured  100  per  cent,  of  those 
cases  which  came  under  treatment  with  tuberculin  in  the 
earliest  stage  of  the  disease  (Jessen,  Turban,  Wilkinson, 

1  Therapeutic  Gazette,  1903,  p.  163.  The  references  to  other 
authors  in  the  following  paragraphs  are  taken  from  this  article. 


Klebs,  Petrushky).  Von  Ruck  claims  93  per  cent.,  Trudeau 
83  per  cent.,  and  Rembold  75  per  cent,  of  cures  in  similar 
cases.  In  all,  589  cases  treated  with  tuberculin  came  under 
consideration,  with  a  proportion  of  cures  equivalent  to  84-2 
per  cent.  On  the  other  hand,  among  611  collected  cases 
which  were  treated  in  the  ordinary  way  without  the  aid 
of  "culture  products,"  391,  or  64  per  cent.,  were  regarded 
as  cured. 

The  results  obtained  by  individuals  with  and  without 
tuberculin,  as  quoted  by  the  same  writer,  are  of  considerable 
interest.  Trudeau,  in  his  first  report  on  the  remedy, 
recorded  24  cases  treated  with  tuberculin,  with  a  per- 
centage of  cures  of  83.  Among  113  cases  treated  without 
it  he  cured  72  per  cent.,  giving  a  difference  of  11  per  cent, 
in  favour  of  the  remedy.  More  recently  he  gives  the  results 
of  94  cases,  47  treated  with,  and  the  same  number  without, 
tuberculin  ;  of  the  former  group  41  were  cured,  of  the 
latter  36 — again  a  small  difference  in  favour  of  Koch's 
preparation. 

Turban  gives  details  of  his  results  in  cases  which  came 
under  treatment  in  the  first,  second,  and  third  stage1  of  the 
disease  respectively.  Taking  the  last  first :  he  found  that, 
whereas  the  mortality  in  cases  treated  without  tuberculin 

1  For  purposes  of  classification  in  statistics  of  sanatoria,  etc.,  pul- 
monary tuberculosis  is  divided  into  three  stages.  Different  authorities 
have  devised  slightly  different  methods  of  classification.  That  of 
Turban,  which  may  be  taken  aa  typical,  is  into — First  stage : 
Cases  in  which  only  one  lobe  is  affected,  or  only  portions  of  two  lobes 
equivalent  to  one  lobe  in  extent.  Second  stage ;  Cases  in  which 
two  lobes  are  extensively  involved.  Third  stage:  Cases  in  which 
the  disease  is  still  further  advanced.  It  will  be  seen  that  this  classifi- 
cation is  purely  arbitrary,  and  merely  affords  a  rough  indication  of 
the  severity  of  individual  cases.  It  does  not  correspond  at  all  with 
the  well-known  pathological  division  into  the  stages  of  (1)  tubercular 
deposit,  (2)  consolidation.  (3)  excavation  or  cavity-formation.  It  is 
practically  impossible  to  ascertain  with  any  exactitude  the  extent 
of  the  pathological  changes  in  the  lung  from  a  study  of  the  physical 
signs ;  the  pathological  classification  is  therefore  not  available  for 
practical  use. 


TUBERCULIN    IN    CONSUMPTION         319 

was  50  per  eent.  within  a  period  of  two  years,  among  those 
treated  with  tuberculin  only  '25  per  cent,  died  within  the 
same  time-limit.  He  did  not  find  that  tuberculin  had  any 
tendency  to  induce  attacks  of  haemorrhage  in  these  cases, 
rior  did  it  ever  give  rise  to  a  generalized  tuberculosis. 
Tubercle  bacilli  disappeared  from  the  sputum  in  four  cases 
out  of  21  in  which  tuberculin  was  used.  Of  course  a  real 
cure  was  not  to  be  hoped  for  in  patients  coining  for  treat- 
ment at  so  advanced  a  stage  of  the  disease. 

Of  48  patients  in  the  second  stage  of  the  disease,  treated 
with  tuberculin,  36  were  alive  four  years  afterwards ; 
whereas,  of  152  who  did  not  receive  injections,  107  survived 
for  the  same  length  of  time.  The  figures  do  not  themselves 
prove  much  in  favour  of  tuberculin,  but  Turban  considers 
that  the  actual  condition  of  the  various  patients  afforded 
strong  evidence  of  its  value.  Of  cases  which  came  under 
treatment  in  the  first  stage  of  the  malady,  Turban,  as 
already  stated,  claims  100  per  cent,  of  cures.  In  all  the 
cases  in  this  stage  of  the  malady  in  which  tubercle  bacilli 
were  at  first  found  in  the  sputum,  they  disappeared  under 
treatment.  Taking  this  last  as  a  test  of  the  value  of  tuber- 
culin, he  shows  that  of  a  total  of  86  cases  so  treated,  45 
(52  per  cent.)  were  permanently  freed  from  the  organisms ; 
whereas,  of  241  patients  not  so  treated,  95  (39  per  cent.) 
only  were  similarly  benefited. 

Denys  made  trial  of  tuberculin  alone,  without  the  aid 
of  other  remedial  measures,  such  as  rest,  open  air,  and 
medicines.  He  claims  to  have  cured  in  this  way  29  per 
cent,  of  his  cases  (174),  and  greatly  benefited  another  42 
per  cent.  As  was  previously  pointed  out,  there  is  no  reason, 
except  for  purely  experimental  purposes,  to  suspend  ordinary 
hygienic  measures  during  the  administration  of  tuberculin  ; 
in  order  to  produce  the  maximum  of  advantage  to  the 
patient  the  two  should  be  combined. 

Wurtzen1  recorded  good  results  obtained  in  10  cases 
with  the  old  tuberculin,  given  according  to  the  rules 
1  Tuberculosis  Bull.  Mem.,  Feb.,  1904,  p.  53. 


320       SERUMS,    VACCINES,    AND    TOXINS 

advised  by  Goetsch,1  viz.  never  to  inject  febrile  patients  ; 
never  to  increase  the  dose  till  the  previous  amount  can  be 
tolerated  without  reaction ;  and  to  insist  on  rest  in  bed  on 
the  day  of  treatment  and  the  following  day. 

Within  the  last  decade,  largely  owing  to  the  work 
of  Wright,  a  considerable  impetus  has  been  given  to  the 
use  of  tuberculin  in  pulmonary  tuberculosis,  and  with  the 
adoption  of  smaller  doses  the  proportion  of  successful  results 
would  seem  to  have  risen.  The  majority  of  writers  on  the 
subject  are  in  favour  of  the  employment  of  the  remedy.2 
Nevertheless  it  is  very  difficult  to  obtain  valid  evidence  of 
actual  benefit  arising  from  its  use  in  this  form  of  tubercular 
disease,  and  voices  of  might  have  recently  been  raised  on 
the  other  side.  Karl  Pearson,  as  the  result  of  an  extended 
study  of  statistical  material  available  at  King  Edward's 
Sanatorium  at  Midhurst,  concludes  that  no  proof  of  bene- 
ficial action  is  therein  afforded.  Bardswell3  concludes  "  that 
the  administration  of  tuberculin  is  quite  unsuitable  as  a 
routine  method  of  treatment  for  all  cases  of  pulmonary 
tuberculosis,  and  that  its  indiscriminate  and  careless  use  on 
a  large  scale  can  only  end  in  disaster." 

There  is  also  a  difference  of  opinion  as  to  what  cases 
are  best  adapted  for  the  treatment.  Thus,  Am  rear*  and 
Eoemisch  5  would  restrict  the  use  of  the  remedy  to  chronic 
cases  without  fever,  and  Lawson  and  Stewart0  agree  with 
this  advice  ;  whereas  Krause  7  and  Hammer  8  do  not  regard 
fever  as  a  contraindication.  Haemoptysis  is  not  always 

1  Deuf.  med.  Woch.,  June  20,  1901. 

2  For  further  information  on  the  use  of  tuberculin,  reference  should 
be  made  to  the  treatises — by  Sahli,  "  Ueber  Tuberkuliubehandlung  "  ; 
by  Bandolier  and  Koepke,  "  Tuberkulinbehandlung  and  Tuberkulose- 
iminunitiit "  ;  and  by  Riviere  and  Morland,  "  Tuberculin  Treatment." 

3  Lancet,  1915,  i.  68. 

4  Beitr.  z.  Klin.  d.  Tuberk.,  Bd.  iv.,  Heft  2. 

5  Munch,  med.  Woch.,  1906,  No.  3. 

6  Lancet,  1905,  ii.  1679. 

7  Munch,  med.  Woch.,  1905,  No.  32. 

8  Ibid.,  1906,  p.  2423. 


TUBERCULIN    TREATMENT  321 

looked  upon  as  a  bar  to  the  cautious  use  of  the  new  tuber- 
culin for  remedial  purposes,  though  it  is  so  to  the  diag- 
nostic use  of  the  old  tuberculin  :  it  is  even  suggested  that 
tuberculin  is  valuable  as  an  agent  for  arresting  haemorrhage. 
A  few  writers  still  recommend  the  old  tuberculin  for  purposes 
of  treatment  (Foss,1  Jacquerod  2) ;  but  "T.R."  is  the  form 
usually  adopted.  The  emulsion  of  the  bacilli  is  preferred 
by  some  (Krause,3  Elsaesser,4  Poppelmann  5),  and  has  also 
been  used  by  Wright.  It  has  the  advantage  of  cheapness. 
Great  caution  must  be  observed  and  very  minute 
initial  doses  given,  if  it  be  decided  to  administer  the  remedy 
to  patients  who  suffer  from  pyrexia,  as  considerable  harm 
may  be  done  by  doses  which  excite  any  strong  reaction- 
The  question  of  dosage  is  discussed  later  (pp.  334-6). 

TUBERCULIN  IN  SURGICAL  TUBERCULOSIS 

We  have  already  mentioned  that  it  was  as  a  cure  for 
consumption  that  tuberculin  was  first  announced  to  the 
world,  and  that,  when  the  extravagant  hopes  thus  raised 
were  disappointed,  the  pendulum  swung  too  far  in  the 
opposite  direction,  and  the  valuable  properties  of  the  pre- 
paration were  overlooked.  Some  attempts  were  indeed 
made  to  maintain  the  value  of  tuberculin  in  the  treatment 
of  lupus  ;  but  as  a  remedy  in  other  kinds  of  tuberculosis 
it  fell  into  entire  disuse.  Yet  there  is  little  doubt  that  in 
some  at  least  of  the  varieties  of  lupus  very  favourable 
results  may  be  obtained  by  a  proper  use  of  tuberculin, 
or  that  it  deserves  trial  in  all  obstinate  cases  which  resist 
other  remedies.  As  we  have  already  pointed  out,  the 
respective  actions  of  the  old  tuberculin  and  of  the  new 
(T.R.)  are  quite  distinct;  hence  they  must  be  con- 
sidered  separately. 

1  Zdtschr.  f.  Tuberk.,  Bd.  vi.,  Heft  5. 

2  Rev.  Med.  de  la  Suisse  Romande,  1906,  No.  2. 

3  Op.  cit. 

4  Deut.  med.   Woch.,  1905,  No.  48. 

5  Berl.  Min.  Woch.}  905,  No.  36. 


322       SERUMS,    VACCINES,    AND    TOXINS 
Tuberculin  in  the  treatment  of  lupus  vulgaris.— 

Very  good  results  were  claimed  in  this  disease  from  the  use 
of  the  old  tuberculin  when  it  was  first  introduced  (1890). 
Koch 1  in  his  original  paper  wrote  as  follows  :  "  A  few 
hours  after  the  injection  into  the  skin  of  the  back  .  .  . 
the  lupus-spots  begin  to  swell  and  redden  ;  and  this  they 
generally  do  before  the  initial  rigor.  During  the  fever 
swelling  and  redness  increase,  and  may  finally  reach  a  high 
degree,  so  that  the  lupus-tissue  becomes  brownish  and 
necrotic  in  places.  Where  the  lupus  had  been  sharply 
defined  we  sometimes  found  a  much-swollen  and  brownish 
spot  surrounded  by  a  whitish  edge  about  a  centimetre  wide, 
which  again  was  surrounded  by  a  broad  band  of  bright  red. 
After  the  subsidence  of  the  fever  the  swelling  of  the  lupus- 
tissue  decreases  gradually,  and  disappears  in  about  two  or 
three  days.  The  lupus-spots  themselves  are  then  covered 
by  a  crust  of  serum,  which  filters  outwards  and  dries  in 
the  air ;  they  change  to  crusts,  which  fall  off"  after  two  or 
three  weeks,  and  which  sometimes  leave  a  clean  cicatrix 
behind  after  one  injection.  Generally,  however,  several 
injections  are  required  for  the  complete  removal  of  the 
lupus-tissue.  .  .  .  There  is  no  question  of  the  destruction 
of  the  tubercle  bacilli  in  the  tissues ;  it  is  only  the  tissue  en- 
closing the  tubercle  bacilli  which  is  affected  by  the  remedy." 
Striking  results  were  also  recorded  by  other  observers. 
Thus,  Saundby,  Simon,  and  Gilbert,3  in  a  communication 
to  the  Birmingham  Medical  Review,  though  speaking  cau- 
tiously of  the  reswlts  achieved  by  the  use  of  the  remedy, 
yet  allude  to  remarkable  improvement  as  taking  place  in 
this  disease ;  and  Heron,  at  the  Medical  Society  of  London, 
stated  that  this  was  so  marked  that  tuberculin  would  soon 
be  regarded  as  an  essential  in  the  treatment  of  lupus. 
Barling  3  recorded  14  cases  of  lupus  treated  by  this  means, 

1  Deut.  med.  Woch.,  1890;  Brit.  Med.  Jottni.,  1890,  ii.  1193. 

2  Brit.  Med.  Journ.  Epitome,  Dec.  20,  1890,  p.  92. 

'      3  Quoted  in   Brit.  Med.  Journ.  leading   article,   April  25,  1891, 
p.  91-2. 


TUBERCULIN    IN    LUPUS    VULGARIS      323 

of  which  4:  were  very  much  improved,  8  considerably  so, 
'2  slightly  benefited.  Soon,  however,  less  favourable  re- 
ports began  to  come  to  hand.  It  was  found  that,  though 
the  first  effects  were  encouraging,  relapses  were  very 
liable  to  occur.  Radcliffe  Crocker  pronounced  the  remedy 
disappointing  on  the  whole,  and  this  verdict  was  gener- 
ally accepted.  Consequently  tuberculin  fell  into  disuse 
among  the  body  of  the  profession  as  a  method  of  treating 
lupus. 

A  few  cases  are,  however,  still  recorded  from  time  to 
time  in  which  good  results  are  obtained  from  the  use  of  the 
old  tuberculin.  As  an  example  we  may  quote  the  salient 
facts  of  a  case  reported  by  E.  F.  Maynard,1  which  illustrates 
the  use  of  the  remedy.  The  patient  was  a  cook,  aged  40, 
who  had  suffered  from  lupus  of  the  nose  for  some  time,  and 
had  been  treated  for  the  past  three  years  by  scraping  and 
cautery  (acid  nitrate  of  mercury,  fuming  nitric  acid,  etc.) 
without  permanent  benefit.  The  disease  was  advancing, 
and  had  involved  the  septum  nasi.  "  Old  tuberculin  "  was 
administered,  beginning  with  doses  of  O'OOl  c.c.  injected 
into  the  arm.  The  site  of  injection  became  red,  swollen 
and  painful,  and  the  temperature  rose  from  99  -8°.  F.  to 
102 '4°  F.  There  ensued  headache,  nausea,  and  feeling  of 
illness,  and  the  nose  became  painful,  red,  and  swollen.  The 
closes  were  increased  gradually.  After  0-005  c.c.  had  been 
reached  there  was  no  further  reaction  till  O'OOT  c.c.  was 
given.  Then  again  no  reaction  occurred  till  a  dose  of 
0-03  c.c.  was  reached.  After  0*09  c.c.  had  been  administered 
no  further  reaction  was  seen,  though  O'l  c.c.  was  given 
several  times  over.  The  disease  healed  up  entirely,  and  no 
relapse  had  occurred  seventeen  months  afterwards. 

In  the  above,  case  the  treatment  by  tuberculin  alone, 
without  the  adoption  of  any  other  measure,  seems  to  have 
effected  a  cure.  The  majority,  however,  of  those  who  are 
in  favour  of  the  use  of  tuberculin  recommend  that  it  should 
be  employed  along  with  surgical  measures,  such  as  scraping. 
1  Jirit.  Mcd.  Joitrn.,  1900,  ii.  1777. 


324       SERUMS,    VACCINES,    AND   TOXINS 

lu  some  instances  it  has  been  combined  with  the  adminis- 
tration of  thyroid  extract,  apparently  with  good  results. 

Local  use. — A  method  of  applying  tuberculin  locally  has 
been  devised  by  Verge,1  who  makes  a  5-per-cent.  ointment 
of  old  tuberculin  with  soft  paraffin,  and  rubs  it  into  the 
lesions  for  one  to  two  minutes,  after  preliminary  cleansing 
with  a  starch  poultice.  Lint  smeared  with  the  ointment  is 
then  applied  under  a  bandage  for  a  period  of  twenty-four 
hours.  The  application  is  repeated  daily  for  three  or  four 
days.  There  may  be  considerable  pain,  and  a  peculiar  odour 
is  evolved.  Healing  takes  place  in  about  ten  days. 

On  the  introduction  of  the  new  tuberculin  (T.R.)  it 
was  tried  in  lupus  by  a  number  of  observers.  Thus, 
Bussenius 3  reported  3  out  of  4  cases  improved,  and 
Worner 3  4  patients  all  benefited,  especially  2  who  suffered 
from  lupus  hypertrophicus.  Doutrelepont  *  treated  1 5  cases 
with  improvement  in  all,  and  van  Horn  5  10  with  equally 
good  results. 

Adrian  gives  a  detailed  account  of  his  treatment  of 
12  cases,  of  which  8  were  apparently  cured,  and  4  did 
not  entirely  yield  to  the  remedy.  The  table  on  the 
next  page  is  taken  from  one  of  his  articles,  the  results 
being  added  in  a  separate  column. 

The  rise  of  temperature  following  the  injections  was 
generally  marked  ;  and  sometimes  a  rigor  occurred.  The 
headache  and  general  feeling  of  illness  were  parallel  to 
the  rise  of  temperature.  The  latter  was  more  often  met 
with  after  use  of  some  particular  specimens  of  tuberculin, 
and  was  more  marked  in  some  patients  than  in  others.  It 
was  found  that,  if  one  dose  had  produced  too  great  a  reaction, 
it  was  necessary  to  reduce  the  amount  used  to  a  figure  very 
much  lower,  even  to  a  point  below  that  at  which  no  reaction 

]  Brit.  Mcd.  Jottm.,  1!)10,  ii.  2023. 

*  Deut.  meA.   Wocli.,  1897,  No.  28,  p.  4-11, 

3  Ibid..  No.  30,  p.  476. 

4  Ibid.,  No.  37,  p.  537. 
•'  Tbid..  No.  39,  p.  G2'>. 


TUBERCULIN    IN    LUPUS    VULGARIS      325 


Case 

Sex  and  age 

Dose 

No.  of 
injections 

Duration  of 
treatment 

Result 

1 

Female     19 

1/1000  increased 

to     20 

50 

132  days 

Cured. 

2 

20 

1/500 

20 

43 

129 

3 

17 

1/500 

20 

35 

115 

4 

„          39 

1/1000 

20 

47 

143 

5 

27 

1/500 

20 

36 

114 

6 

Male        32 

1/500 

20 

36 

87 

7 

Female     14 

1/1000 

20 

(X    4) 

55 

193 

8 

6 

1/1000 

20 

61 

216 

9 

48 

1/500 

12 

67 

199 

Not  tur'd 

10 

14 

1/500 

2-5 

68 

156 

11 

35 

1/500 

2/10 

31 

84 

12 

56 

1/1000 

4/10 

49         15o 

had  previously  been  met  with.  Transitory  febrile  albu- 
minuria  was  not  uncommon,  and  in  one  case  severe  albu- 
minuria  occurred.  Hyaline  casts  were  sometimes  found  in 
the  urine.  In  no  instance  did  a  local  abscess  ensue  at  the 
site  of  injection,  nor  was  there  urticaria,  herpes,  or  enlarge- 
ment of  glands.  No  local  reaction  is  seen  at  the  site  of  the 
lupus-lesions  when  the  new  tuberculin  is  employed — a  con- 
trast with  the  old  tuberculin. 

In  spite  of  these  apparently  good  results,  Adrian  is  not 
very  favourable  to  the  use  of  tuberculin  (T.R.).  It  is 
exceedingly  expensive,  which  is  undoubtedly  a  drawback 
to  its  use.  Adrian  used  altogether  188  c.c.  of  the  fluid 
in  a  total  of  578  injections,  the  cost  being  1,598  marks, 
or,  approximately,  £80.  He  recommends  the  employment 
of  surgical  measures  as  well  as  the  tuberculin,  and  does  not 
consider  the  new  preparation  any  better  than  the  old. 

Mayer1  practically  agrees  with  this  verdict,  holding 
that  tuberculin  may  do  good  in  lupus,  but  that  it  is  not 
superior  to  ordinary  measures;  while  Bussenius  and 
Cossmann  ~  report  that  no  constant  improvement  occurs  in 

1  Arcli.f.  Derm.  u.  Syph.,  1898,  xlii.  267. 

2  "  Das  Tuberculin  T.R.  und  sein  Wirkung."     Berlin,  1898.     Cf. 
Bussenius,  Dent.  med.  Woch.,  1897,  No.  28,  p.  441. 


326       SERUMS,    VACCINES,    AND   TOXINS 

all  cases.  "  It  cannot  be  denied,"  they  write,  "  that  Koch's 
T.R.,  injected  in  accordance  with  Koch's  directions,  may 
have  a  good  effect  on  a  focus  of  lupus  ;  yet  our  failures  and 
the  negative  results  recorded  by  others  show  that  such  a 
favourable  result  is  not  an  absolute  certainty."  On  the 
other  hand,  Broccbieri1  considers  that  the  new  tuberculin 
is  superior  to  the  old  in  the  treatment  of  lupus,  and  may 
succeed  where  the  latter  has  failed.  He  thinks  that  the 
spread  of  the  disease  is  prevented  by  its  employment.  The 
duration  of  treatment  should  not  be  less  than  one  year. 
More  recently  favourable  reports  of  its  value  have  been  given 
by  Bulloch2  and  by  Darier.3  Bandelier  *  found  benefit  to 
result  from  the  use  of  "perlsucht  tuberculin. 

On  theoretical  grounds  it  would  seem  reasonable  to 
make  use  of  the  two  forms  of  tul>erculin  in  conjunction  for 
the  treatment  of  lupus — using  the  old  preparation  until  the 
necrotic  tissues  are  thrown  off,  and  then  administering  the 
new  tuberculin  in  order  to  produce  immunity,  and  thus 
prevent  subsequent  relapse  and  spread  of  the  disease. 

Tuberculin  in  tubercular  laryngitis. — Very  much 
the  same  results  were  obtained  by  the  use  of  the  old 
tuberculin  in  laryngeal  phthisis  as  in  the  case  of  lupus. 
Good  effects  were  at  first  reported,  as  by  Struebing,5  who 
recorded  a  case  in  which  great  benefit  ensued  as  the  result  of 
this  treatment.  There  was  at  first  a  period  in  which  there 
were  increased  hoarseness,  and  pain  in  the  throat — effects 
of  the  local  reaction.  After  nine  injections  the  surface  of 
the  lesions  looked  cleaner  and  healthier,  final  cicatrization 
being  produced  after  forty-three  doses  of  the  remedy.  The 
ulceration  ultimately  seemed  to  be  entirely  cured.  Lennox 
Brown  6  reported  Gerhardt's  results  in  19  cases,  17  of  which 

1  II  Policlinico,  1898,  No.  21,  p.  189. 
-  Lancet,  1905,  ii.  1603. 

3  Ann.  de  Dermatol.,  1905,  p.  2  i'.i. 

4  Seitr.  c.Klin.  der  Tuberk.,  vi.  115. 

5  Deut.  med.  Jf'och.,  Oct.  8,  1891. 

8  lir'ti.  Med.Journ.,  1890,  ii.  1485. 


TUBERCULIN    IN    LOCALIZED   DISEASE    327 

were  much  improved,  only  2  failing  to  receive  any  benefit. 
Senator l  also  reported  marked  improvement  in  cases  which 
he  had  treated.  The  same  doubt,  however,  as  to  the  per- 
manence of  the  good  effects  produced  by  tuberculin  exists 
in  this  disease  as  in  lupus,  and  it  is  not  now  often  employed. 

Soon  after  the  new  tuberculin  was  introduced,  Hersfeld  3 
recorded  7  cases  in  which  he  made  use  of  it.  He  noted 
that  the  solutions  keep  badly,  and  that  a  glycerin  solu- 
tion is  more  painful  to  the  patient  than  a  saline  solution. 
Bandelier  and  Roepke  3  find  the  remedy  of  great  value  in 
this  affection,  practically  doing  away  with  the  need  for  local 
treatment  in  early  cases.  Pottenger l  found  von  Ruck's 
tuberculin  of  use,  and  Krause  5  used  the  emulsion  of  bacilli 
with  advantage. 

We  have  personally  treated  6  cases  of  tuberculous 
laryngitis  with  T.R.,  and  in  4  of  these,  where  the  disease 
was  localized  to  the  larynx,  complete  recovery,  with  strong, 
though  harsh,  voice,  took  place  ;  but  in  2  cases  associated 
with  extensive  lung-mischief,  although  laryngeal  improve- 
ment followed  the  use  of  the  remedy,  the  pulmonary  lesions 
progressed  and  death  ensued  within  twelve  months. 

Tuberculin  in   disease  of   bones  and  joints.— 

The  old  tuberculin  produces  phenomena  of  swelling  and 
redness  around  tuberculous  joints,  just  as  it  does  around 
patches  of  lupus.  Koch  6  reported  as  follows  in  his  original 
paper  : — "  Glandular,  bone-,  and  joint-tuberculosis  were 
similarly  treated,  large  doses  at  intervals  being  employed. 
The  result  was  the  same  as  in  the  lupus-cases — a  speedy 
cure  in  recent  and  slight  cases,  and  slow  improvement  in 
severe  cases."  In  spite  of  encouraging  results  recorded  by 
some  authors  at  first,  the  general  verdict  was  ultimately 

1  Berl.  Min.  Woch.,  Dec.  10,  1890. 

2  Deut.  med.  Woch.,  Aug.  19,  1897,  p.  543. 

3  Op.  supra  cit. 

4  Amer.  Journ.  Mod.  Sci.,  Dec.,  1906. 

5  Munch,  med.  Woch.,  1905,  No.  32. 
('  Loc.  cit. 


328       SERUMS,    VACCINES.    AND    TOXINS 

unfavourable  to  the  use  of  tuberculin  in  these  cases,  most 
observers  apparently  agreeing  with  Edmund  Owen  that  the 
final  results  gained  were  no  better  than  could  be  produced 
by  rest  alone. 

Of  the  new  tuberculin,  Adrian1  reported  that  it  had  no 
effect  on  disease  of  bone  or  glands.  On  general  grounds  it 
seems  unlikely  that,  if  it  raises  the  general  resisting-power 
of  the  body,  it  should  have  no  effect  on  these  special 
forms  of  the  disease.  No  doubt  it  is  difficult  to  ascertain 
the  exact  amount  of  improvement  produced  by  it,  as  it  has 
no  local  effect  of  a  visible  kind.  Theoretically  it  would 
seem  that  the  new  rather  than  the  old  tuberculin  should  be 
tried  in  these  cases,  as  they  are  deeply  seated,  and  there  is 
no  means  of  escape  for  the  necrotic  material,  if  it  be  cast  off 
as  a  result  of  treatment  with  old  tuberculin. 

Recently  good  results  have  been  reported  by  Gray2  and 
by  Low.3  A  case  of  hip-disease  benefited  by  tuberculin  is 
recorded  by  Crofton,1  and  our  own  observation  of  a  con 
siderable  number  of  cases  of  tuberculous  hips,  knees,  and 
wrists,  treated  either  in  the  wards  of  a  hospital  or  as 
out-patients,  leads  us  to  regard  T.R.  as  a  most  valuable 
remedial  agent  resulting  in  the  majority  of  cases  in  com- 
plete cure,  the  affected  joints  being  freely  movable. 

Tuberculin  in  ophthalmic  disease.  —  Eyre  and 
Ormond  5  record  complete  cure  following  the  use  of  T.R. 
in  a  case  of  extensive  tuberculous  disease  of  the  con- 
junctiva. Eyre6  has  subsequently  reported  a  series  of  11 
cases,  of  which  8  were  cured,  2  much  improved,  and  1  not 
benefited.  Reuchlein 7  reports  favourably  on  the  use  of 
the  preparation  in  ocular  diseases  (iritis,  keratitis,  disease 

1  Op.  tit. 

2  Lancet,  1906,  i  1099. 

*  Brit.  Med.  Journ.,  1908,  i.  550. 

4  Lancet,  1908,  ii.  731. 

5  Trans.  Ophthalm.  Soc.,  1907,  p.  27. 

8  Hunterian  Lectures,  R.C.S.,  1912  ;  Lancet,  1912.  i.  1319. 
7  Klin.  Monatth.  f.  Avgenheilk.,  1906,  i.  352. 


VACCINATION  AGAINST  TUBERCULOSIS    329 

of  the  ciliary  body).  Erdmann 1  also  used  this  method  of 
treatment  with  advantage,  and  we  have  seen  considerable 
benefit  accrue  in  cases  of  tubercular  iritis,  of  tubercles  in 
the  choroid,  and  of  tuberculous  periostitis  of  the  orbit. 

Tuberculin  in  genito -urinary  and  peritoneal  dis- 
ease.— In  the  experience  of  the  present  writers,  tuberculin 
(T.K.)  finds  its  most  successful  application  in  tuberculous 
infections  of  the  genito-urinary  tract — indeed,  where  the 
disease  is  bilateral  and  involves  the  bladder  as  well,  so  that 
surgical  measures  are  out  of  the  question,  the  administration 
of  tuberculin  holds  out  the  only  hope  of  prolongation  of  life. 
One  of  our  patients,  whose  life  could  to  all  appearances  be 
measured  by  weeks  only,  recovered  sufficiently  to  lead  a 
useful  life  for  another  two  and  a  half  years. 

Pardoe  -  recommends  the  use  of  tuberculin  in  cases  of 
tuberculosis  of  the  bladder,  ureters,  and  kidneys.  Birn- 
baum  3  also  reports  good  results  in  cases  of  tuberculosis  of 
the  bladder,  kidney,  and  uterine  adnexa,  and  in  tubercular 
peritonitis.  Bandelier  and  Roepke  4  confirm  the  value  of 
tuberculin  in  the  peritoneal  affection. 

For  dosage  see  pp.  334-6. 

VACCINATION  AGAINST   TUBERCULOSIS 

Attenuation  of  tubercle  bacilli. — For  the  purpose 

of  vaccination  against  any  disease,  the  first  requisite  is  the 
preparation  of  an  attenuated  form  of  the  causal  organism, 
and  for  a  long  time  it  seemed  as  if  it  were  impossible 
to  reduce  the  virulence  of  the  tubercle  bacillus.  Many 
observers  "'  have,  however,  now  succeeded  in  the  endeavour 
to  attenuate  this  organism,  and  in  the  case  of  the  lower 
animals  it  has  been  claimed  that  immunity  can  be  produced 

*  Munch,  med.  Wfch.,  1907,  p.  671. 

2  Lancet,  1905,  ii.  1766. 

3  Centralbl.f.  Gyntik.,  1907,  No.  3. 

4  Op.  supra  sit. 

5  Salmon  (Philadelphia  Med.  Journ.,  June  13,  1903,  p.  966)  gives  an 
historical  summary  of  the  results  obtained  in  attenuating  the  tubercle 
bacillus.     The  following  account  is  principally  taken  from  his  paper. 


330       SERUMS,    VACCINES,    AND   TOXINS 

by  means  of  such  cultures.  In  1889  Darenburg1  inocu- 
lated rabbits  with  dead  cultures  of  tubercle  bacilli,  and 
found  that,  though  they  were  at  the  time  made  ill  by 
the  injections,  yet  afterwards  they  were  more  resistant  to 
infection  with  virulent  bacilli.  In  the  same  year  Grancher 
and  Martin 2  prepared  a  series  of  cultures  of  different 
degrees  of  virulence,  and  stated  that  they  had  succeeded 
in  immunizing  rabbits  by  this  means  against  the  disease. 

In  1890  Trudeau3  gave  an  account  of  two  cultures  of 
tubercle  bacilli  of  very  different  virulence.  The  first  was 
from  the  lung  of  a  man  who  had  died  of  miliary  tuber- 
culosis. It  grew  very  slowly  on  glycerin-agar  in  isolated 
scaly  masses.  The  second  was  from  a  guineapig  which  had 
been  inoculated  with  bacilli  from  an  old  phthisical  cavity, 
and  the  bacilli  had  been  grown  for  a  long  time  on  artificial 
media.  This  culture  grew  rapidly,  forming  a  thick,  creamy 
pellicle  on  the  surface  of  the  medium.  It  was  much  less 
virulent  for  rabbits  than  the  former.  Trudeau  failed,  how- 
ever, to  produce  immunity  by  injection  either  of  culture- 
products  or  of  attenuated  organisms.  In  the  year  1894  he 
announced  that  rabbits  inoculated  with  avian  bacilli  seemed 
to  gain  a  certain  amount  of  additional  resistance  to  the 
human  form.  Guineapigs,  which  are  scarcely  susceptible 
to  the  avian  bacillus,  are  not  protected  by  injections  of  it 
against  infection  with  other  forms. 

In  1894  de  Schweinitz,  by  repeated  subcultures,  had  pro- 
duced a  bacillus  which  was  so  attenuated  that  it  no  longer 
produced  tuberculosis  even  in  guineapigs,  and  by  inoculat- 
ing the  animals  with  these  attenuated  bacilli,  and  afterwards 
with  others  of  gradually  ascending  degrees  of  virulence,  he 
immunized  them  against  bovine  bacilli.  In  1897  the  same 
observer  showed  that  by  injection  with  human  tubercle-bacilli 
cows  could  be  rendered  immune  to  the  bovine  bacillus. 

It  is  interesting  to  notice  that  the  better  a  variety  of  the 

1  Bull,  de  T  Acad.  de  Mcd.,  Oct.  29,  1889,  p.  391. 

a  Ibid.,  Aug.  20,  1890. 

3  Trans.  A**oc.  Amtr.  r/iy*ician*,  1890,  v.  183.     1  !>',<?..  IMM.  ix.  1G8. 


ATTENUATION  OF  TUBERCLE  BACILLI    331 

tubercle  bacillus  grows  on  artificial  media,  the  less  virulent 
it  appears  to  be.  The  artificial  pabulum  constitutes  a  new 
environment  to  which  the  organism  has  to  get  accustomed, 
and  as  it  does  so  it  loses  its  original  power  of  acting  as  a 
parasite.  This  forms  a  good  example  of  the  variation  of 
bacteria  according  to  their  surroundings. 

Behring l  claims  that  by  injection  of  human  tubercle- 
bacilli  into  cattle  he  has  produced  immunity  to  the  bovine 
form  of  the  disease.  The  procedure,  which  he  speaks  of  as 
"  Jennerization,"  is  harmless  to  the  animals,  and  they  sub- 
sequently resist  not  only  artificial  inoculation  with  their 
own  form  of  tuberculosis,  but  also  infection  in  the  ordinary 
course  of  nature  when  they  are  brought  into  contact  with 
other  animals  suffering  from  the  disease.  The  duration  of 
the  immunity  thus  conferred  is  not  yet  certainly  known  ;  a 
second  vaccination  may  be  necessary  subsequently.  Behring 
suggests  that  this  latter  might  be  performed  with  modified 
bovine  bacilli. 

Friedmann 3  has  made  use  of  bacilli  derived  from  the 
tortoise  for  immunizing  warm  -  blooded  animals ;  and 
Moeller 3  has  experimented  with  similar  bacilli  from  the 
slow-worm.  Both  authors  record  good  results ;  but  the 
method  has  not  been  tried  on  man. 

In  human  beings  prophylactic  injection  of  attenuated 
bacilli  does  not  seem  to  have  as  yet  been  attempted ;  while 
it  is  evident  that  the  danger  of  using  living  tubercle-bacilli 
as  a  vaccine  for  human  beings  is  too  great  to  be  faced. 
Maragliano,4  however,  announces  that  he  has  prepared  a 
vaccine  of  a  non-living  nature,  which  he  has  employed 
on  human  beings,  but  the  exact  mode  of  preparing  this 
material  is  not  stated  in  his  communication.  The  use  of  it 

1  Zeitschr.f.  Thiermediein,  Bd.  vi.,  Hft.  5  u.  6. 

2  Therap.  Monatsh.,  March,  1904,  p.  123.    '  Cf.  Friedmann's  .  tuber- 
culin, p.  281. 

3  Zcitschr.  f.  Tttbcrlt.  u.  Heiht.,  Jan.,  1904. 

4  Communication  to  the  International  Medical  Congress,  Madrid, 
1903  ;  Mcd.  Mies,  July  4,  1903,  p.  1. 


332       SERUMS,    VACCINES,    AND    TOXINS 

is  said  to  result  in  an  increase  of  the  agglutinative  power  of 
the  blood-serum,  and  also  in  a  marked  leucocytosis.  These 
are  the  changes  that  have  been  observed  in  the  blood  of 
animals  which  have  been  immunized  against  the  tubercle 
bacillus  experimentally.  The  injections  of  Maragliano's 
vaccine  are  followed  in  human  beings  by  the  development  of 
a  small  tubercular  ulcer  at  the  point  of  inoculation,  accom- 
panied by  a  form  of  suppuration  which  is  bacteriologically 
sterile.  There  is  fever  for  a  few  days,  but  no  other  ill 
effect.  Behring1  suggests  that  it  may  be  possible  to  im- 
munize young  children  prophylactically  with  antibodies 
derived  from  animals  which  have  been  injected  with 
attenuated  bacilli,  and  also  administers  tulase  (p.  280)  in 
milk  for  the  same  purpose. 

Yon  Ruck  used  his  tuberculin  (p.  278)  for  immuniza- 
tion, and  treated  altogether  339  children,  giving  0'05  c.c. 
to  nurslings,  and  0-2-0-6  c.c.  to  older  children. 

VACCINES  IN  TUBERCULOSIS 

Gray  2  has  used  streptococcic  and  staphylococcic  vaccines 
in  cases  of  tuberculosis  of  bones,  joints,  and  glands  with 
advantage;  the  doses  being  500-1,000  millions  of  staphylo- 
cocci,  and  100-250  millions  of  streptococci.  We  find  this 
method  of  treatment  extremely  valuable  in  all  forms  of 
tubercular  lesions  which  have  become  secondarily  infected 
with  pyogenic  bacteria. 

Habershon 3  speaks  highly  of  the  value  of  vaccines  of 
Micrococcus  cntarrhalis,  Diplococcus  pneumonice,  and  the 
pneumobacillus  of  Friedlander  in  cases  of  pulmonary  tuber- 
culosis with  secondary  infection,  but  finds  the  results  dis- 
appointing in  the  presence  of  pneumococcus  and  streptococcus. 

ADMINISTRATION   OF  TUBERCULIN 

At  the  present  time  there  are  two  chief  methods  of 
administering  tuberculin.  The  first — that  originally  prac- 

1  Berl.  klin.  JToc/i.,  March  16,  1903. 

2  Lancet,  1906,  i.  1099. 

3  Bristol  Med.-Cl/ir.  Joxm..  June,  11*14. 


CHOICE    OF   TUBERCULIN  333 

tised  by  Koch — consists  in  the  rapid  increase  in  the  dosage 
at  short  intervals  in  the  attempt  to  produce  a  tolerance 
of  the  remedy  ;  and  the  second,  which  results  from  the 
teaching  of  Wright,  consists  in  the  administration  of  a 
series  of  small  doses  increased  in  size  very  gradually  at 
considerable  intervals,  with  the  object  of  producing  a  real 
immunity.  Each  method  has  secured  numerous  advocates, 
and  even  now  the  difficulty  of  collating  any  really  consider- 
able number  of  cases  with  a  view  to  obtaining  statistical 
evidence  of  a  reliable  character  is  so  great  that  the  relative 
merits  of  the  two  methods  remain  an  open  question.  Our 
own  predilection  is  for  that  method  which  attempts  to 
produce  a  real  immunity  rather  than  the  one  which 
merely  aims  at  a  toxin-tolerance. 

CHOICE   OF  TUBERCULIN,   AND  DOSAGE 
The  various  modifications  of  tuberculin  may  be  classed 
under  one  of  three  forms  : — 

1.  Those  containing  the  soluble  products  of  the  tubercle 
bacillus  or  exotoxins,  e.g.  Old  Tuberculin. 

2.  Those  containing  bacterial  protoplasm  or  endotoxins 
only,  e.g.  New  Tuberculin. 

3.  Those    containing   both    exo-   and    endotoxins,    e.g. 
Bacillary  Emulsion. 

In  ordinary  vaccine  work  the  object  aimed  at  is  the 
production  of  antibodies  capable  of  destroying  the  re- 
sponsible bacteria  and  completely  neuti-alizing  all  their 
toxic  activities,  whether  endogenous  or  exogenous.  Hence, 
on  theoretical  grounds  preference  should  be  given  to  the 
bacillary  emulsion — the  ideal  preparation,  of  course,  being 
the  sensitized  B.E.,  if  only  one  could  be  satisfied  that  the 
sensitization  was  adequate  and  complete.  Consisting  as  it 
does  of  solid  particles,  it  is  absorbed  slowly  and  at  an 
\mcertain  rate.  But  for  practical  purposes  we  may  regard 
the  bacillary  emulsion  as  a  combination  of  the  old  and  new 
tuberculins  (T.  +  T.R.),  and  personally  we  consider  the 
dangers  and  disadvantages  of  old  tuberculin  when  used  as  a 


334       SERUMS,    VACCINES.    AND    TOXINS 

therapeutic  agent  completely  to  outweigh  its  possible  utility. 
We  have  no  hesitation  in  expressing  our  preference  for  the 
new  tuberculin  (T.R.),  in  spite  of  its  cost,  reserving  the 
bacillary  emulsion  for  the  final  stages  of  a  satisfactory 
course  of  the  former. 

Koch  advised,  for  the  treatment  of  phthisis  with  the 
old  tuberculin  (T.),  that  the  initial  dose  should  be  O001  c.c., 
and  that  this  should  lie  repeated  about  every  second  day 
till  no  temperature  reaction  followed  its  use.  Then  the 
dose  should  be  raised  to  0*002  c.c.,  and  so  on,  rising  to 
O.'Ol  c.c.,  etc.  In  strong  individuals  it  might  be  possible 
to  raise  the  doses  more  quickly.  In  lupus  the  first  doses 
might  be  larger,  O'Ol  c.c.,  gradually  raised.  As  we  do  not 
advise  the  use  of  this  preparation  therapeutic-ally,  we  need 
not  discuss  the  dosage. 

The  new  tuberculin  is  supplied  in  liquid  condition. 
It  is  an  opalescent  liquid  similar  in  appearance  to  the 
mixture  of  five  or  six  drops  of  milk  with  half  an  ounce  of 
water.  It  must  be  kept  in  a  cool,  dark,  and  dry  store  : 
the  solution  contains  the  soluble  protoplasm  from  10  mg. 
of  dried  bacilli  in  each  cubic  centimetre — the  actual  amount 
of  solid  substance  entering  into  solution  being  2  nig. l 

1  For  dilution  of  the  liquid  20-per-cent.  glycerin  solution  should 
be  employed.  This  is  prepared  by  boiling  20  c.c.  pure  glycerin 
with  80  c.c.  distilled  water  for  fifteen  minutes,  and  then  cooling 
thoroughly  before  use.  The  dilutions  are  preferably  made  in  the 
following  manner  : 

1.  "With  a  1  c.c.  pipette,  calibrated  to  l/10th,  0-3  c.c.  is  withdrawn 

from  the  bottle,  and  mixed  with  2'7  c.c.  20-per-cent.  glycerin 
solution,  making  a  10-per-cent.  dilution. 

2.  From  this  10-per-cent.  dilution  O'l  c.c.  is  taken  and  made  up  to 

10  c.c.  with  glycerin  solution.    Thus  a  1-per-mille  dilution  of 
the  original  fluid  is  obtained.    Two  divisions  or  2/10th  c.c.  of 
a  Koch  or  Pravaz  syringe  of  this  dilution  therefore  contains 
the  initial  dose,  0*0002  c.c.,  of  the  original  fluid. 
Dilutions  which  present  a  turbid  appearance,  or  show  a  deposit 

which  does  not  dissolve    upon    shaking,   must  not   be    employed. 

Generally  the  dilutions  keep  well  for  a  fortnight  in  a  cool  and  dark 

place. 


DOSAGE    OF    TUBERCULIN  335 

With  the  new  tuberculin  (T.Ii.)  the  initial  dose,  accord- 
ing to  Koch,  should  be  0*002  mg.  in  fairly  strong  persons 
(equivalent  to  0-0002  c.c.of  the  preparation,  and  containing 
actually  0-0004  mg.  of  solid  substance)  ;  in  very  weakly 
subjects  it  is  well  to  start  with  0-001  mg.  The  dose  is 
to  be  repeated  every  other  day,  increasing  at  such  a  rate 
as  to  avoid  reaction  as  far  as  possible  ;  the  amount  may 
usually  be  doubled  each  time. 

Doutrelepont,1  who  tried  this  method,  came  to  the  con- 
clusion that  this  rate  of  increase  was  too  rapid.  He  advised 
that  0-002  mg.  should  be  used  for  the  first  dose,  0-004  for 
the  second,  0'006  for  the  third,  and  so  on,  up  to  0'02  mg. 
Then  the  dose  is  to  be  increased  by  0  02  each  time  up  to 
1  mg.  The  dose  should  not  be  repeated  till  the  temperature 
has  fallen  to  normal  after  the  previous  reaction,  and  the 
largest  dose  used  by  Doutrelepont  was  4  mg.  (0-4  c.c.  of 
the  preparation).  The  fresher  the  solution,  the  more  likely 
is  the  occurrence  of  a  marked  reaction. 

Rosenberger 2  gives  0-002  mg.  of  the  new  tuberculin  to 
start  with.  The  administration  is  followed  by  little  febrile 
disturbance,  but  there  may  be  some  headache  and  sleepless- 
ness. The  appetite  is  increased  by  the  treatment.  The  dose 
is  gradually  raised  till  1  mg.  is  reached ;  then  the  old  tuber- 
culin is  begun,  the  initial  dose  of  the  latter  being  O'Ol  c.c. 

Recent  practice  in  this  country  has  tended  in  the  direc- 
tion of  giving  much  smaller  doses  of  tuberculin  than  were 
formerly  used.  Thus,  whereas  0-002  mg.  of  T.B.  was  con- 
sidered a  small  amount  to  give  as  an  initial  dose,  now 
O'OOl  mg.  would  be  looked  upon  as  a  large  dose,  and 
0-00025,  0-0002,  or  0-0001  mg.  is  more  often  given  at 
first.  Still  more  minute  quantities  are  believed  by  some 
physicians  to  b^  capable  of  producing  a  definite  reaction 
and  to  form  effective  doses  for  therapeutic  use  (e.g.  0-00005, 
0-00002,  or  0-00001  mg.).  The  object  to  be  aimed  at"  is 
to  administer  that  amount  which  will  just  fail  to  produce 

1  Deut.  med.  Woch.,  Aug.  19,  1897,  p.  537. 

2  Centralbl.f.  inn.  Mrf.,  1903,  No.  19,  p.  465. 


336       SERUMS,   VACCINES,    AND    TOXINS 

an  appreciable  reaction  in  the  form  of  a  rise  of  temperature, 
headache,  sleeplessness,  or  other  constitutional  disturbance. 
The  first  doses  therefore  should  always  be  small  (e.g. 
0 '00005  mg.),  and  they  should  be  raised  very  gradually 
until  some  signs  of  reaction  occur.  Thus,  a  course  of  in- 
jections might  be  given  as  follows  :  0-00005,  O'OOOl, 
0-0002,  0-0004,  0-0005,  O'OOl  mg.  Or  a  small  dose  such  as 
0-0001  mg.  may  be  maintained  throughout.  We  have  seen  a 
harmful  reaction  ensue  after  a  dose  of  0*001  mg.1 

Another  change  in  the  method  of  administering  tuber- 
culin which  has  been  effected  in  recent  years  is  the  tendency 
to  prolong  the  intervals  between  the  separate  doses.  Thus, 
whereas  they  were  originally  given  daily,  or  on  alternate 
days,  it  is  now  usual  to  let  an  interval  of  7,  10,  14,  or  even 
21  days  elapse  between  the  injections.  Sometimes  it  is 
preferred  to  give  very  small  doses  on  two  consecutive  days, 
and  then  to  wait  for  an  interval.  No  definite  rules  can  be 
laid  down  for  all  cases  :  each  must  be  judged  according  to 
the  special  phenomena  presented. 

That  tuberculin  given  by  the  mouth  is  absorbed  and  pro- 
duces similar  effects  to  those  which  follow  hypodermic  in- 
jection was  affirmed  by  Freymuth  ;  -  but  Kohler,3  who  tried 
this  method  of  administration  for  tlieraj>eutic  purposes,  was 
not  impressed  by  its  advantages.  Calmette  and  Breton4 
state  that  it  is  also  absorbed  by  the  bowel.  More  recently 
Latham5  has  used  the  oral  method  extensively,  and  up- 
holds the  value  of  this  procedure.  For  such  use  the  tuber- 
culin (T.R.)  is  diluted  with  normal  saline  solution.  It 
can  be  given  in  milk,  or  in  any  flavoured  water  if  this  is 

1  These  doses  represent  the  weight  of  dried  tubercle  bacilli  used  in 
their  preparation.  To  ascertain  the  actual  weight  of  soluble  proto- 
plasm contained  in  each,  it  is  necessary  to  divide  the  figure  givtn 
by  5— e.g.  0-0001  mg.  =.  O'OOOOl  c.c.  tuberculin,  and  contains  0-00002 
mg.  bacterial  protoplasm.  -  Quoted  by  Kohler. 

*  Zeittehr.f.  Ttiberk.,  1907,  Hft.  4. 

4  Compt.  Rend.  Acad.  Sci.,  cxliL  11.  Cf.  Lissauer,  Dent.  med. 
Woch.,  1908,  p.  1335. 

§  Prof.  K.  Sot.  Med.,  Clinical  Sect.,  1908,  p.  100. 


preferred,  the  same  doses  being  employed  as  are  used  for 
hypodermic  injection.  On  the  whole,  we  are  not  inclined 
to  recommend  this  method  of  administration,  and  believe 
that  the  evidence  adduced  in  its  favour  is  fallacious. 

Kapralik  and  Schrb'tter l  find  that  tuberculin  is  also 
absorbed  readily  when  administered  by  inhalation  in  the 
form  of  a  spray ;  but  there  seems  to  be  no  advantage  in 
this  inconvenient  mode  of  procedure. 

A  curious  feature  that  is  sometimes  observed  in  the 
course  of  treating  tubercular  lesions  with  tuberculin  is 
that  while  the  original  lesion  is  undergoing  marked  im- 
provement, apparently  as  a  result  of  the  remedy,  some 
new  focus  of  tuberculosis  may  arise  elsewhere,  and  may 
even  run  a  rapidly  progressive  course.  It  is  difficult 
to  explain  this  occurrence  in  view  of  the  general  increase 
in  resistance  that  should  follow  the  appropriate  use  of 
tuberculin. 

SERUM  THERAPEUTICS  OF  TUBERCULOSIS 
Various  attempts  have  been  made  to  treat  tubercu- 
losis by  an  antitoxic  serum  on  the  lines  of  that  used  for 
diphtheria.  To  prepare  the  serum,  horses  or  other  animals 
are  injected  with  gradually  increasing  doses  of  tuberculin 
or  similar  toxic  products  of  the  growth  of  the  organism, 
and  the  serum  obtained  by  subsequent  bleeding  of  the  animal 
is  injected  subcutaneously  into  the  tuberculous  individual. 

Maragliano's  serum. — For  the  preparation2  of  his 
serum,  Maragliano  uses  two  separate  toxins — (1)  a  culture 
of  the  bacilli  concentrated  by  heating  on  a  water-bath  at 
100°  0.  for  three  or  four  days ;  and  (2)  a  similar  culture 
filtered  through  a  Chamberland  filter  and  concentrated 
in  vacuo  at  a  temperature  of  30°  C.  A  mixture,  consist- 
ing of  three  parts  of  the  former  and  one  of  the  latter, 
is  used  to  inoculate  the  horse,  commencing  with  a  dose 
of  2  mg.  per  kilogramme  of  body  weight,  and  gradually 

1   Wien.  Itlin.  Woeh.,  1904,  No.  12,  p.  583. 
-  Quoted  from  Nicholls,  Montreal  Med.  Journ.,  1903,  xxxii.  477. 
W 


338       SERUMS,    VAC  (I  M.S.    AXI)    TOXINS 


increasing  up  to  40  ing.  or  ~>0  nig.  The  immunizing  process 
lasts  altogether  about  six  months,  a  pause  being  made  in 
the  injections  if  the  horse  develops  fever  or  other  signs  of 
illness.  The  serum  is  not  drawn  off  for  a  period  of  three 
or  four  weeks  after  the  injections  have  been  stopped,  until 
the  urine  of  the  animal  ceases  to  contain  toxic  bodies. 
When  it  has  been  prepared,  1  c.c.  of  the  serum  will  counter- 
act the  smallest  dose  of  tuberculin  capable  of  causing  a 
reaction  in  an  infected  individual. 

The  serum  is  administered  in  doses  of  1  c.c.,  which  are 
injected  on  alternate  days.  The  other  means  adapted  to 
the  cure  of  tuberculosis  (open  air  and  good  feeding)  are  not 
omitted  during  the  treatment  with  serum.  The  latter  has, 
of  course,  no  effect  on  the  pyogenic  organisms  which  second- 
arily infect  the  tuberculous  individual  (streptococci,  etc.), 
but  it  is  applicable  to  all  cases,  in  whatever  stage  of  the 
disease  they  may  be,  to  combat  the  actual  tubercle  bacilli. 
The  serum  is  said  to  be  bactericidal  as  well  as  antitoxic, 
since  if  bacilli  are  kept  for  some  days  in  the  fluid  they 
cease  to  cause  infection  when  injected  into  animals,  or  to 
grow  if  planted  on  nutrient  media. 

Some  statistics  of  the  results  obtained  by  the  use  of 
this  serum  are  given  by  Mircoli.1  In  all,  2,899  patients 
came  under  consideration,  and  the  uncomplicated  cases  may 
be  thus  tabulated  : — 


Total 

Cured 

Im- 
proved 

Station- 
ary 

No 
effect 

Circumscribed  apyretic  cases  ... 
Circumscribed  febrile  cases 

250* 
938 

95 
168 

110 
511 

30 
163 

35 
96 

Diffuse  tubercular  bronchitis  ... 
Advanced  phthisis  with  cavities 

6G5f 
712* 

91 
39 

301 
281 

166 
102 

106 
240 

*  (?)  270.  t  (?)  664.  I  (?)  662. 

Such  results  are  certainly  noteworthy.     Mircoli  states 
that   the   improvement   obtained   is   generally  permanent, 
1  Gaz.  degli    OspcdaU,  Sept.  9,  1900 ;    Joitrn.   Amer.  Ned.  Assoc., 
1900,  ii.  887,  914. 


MARMOREK'S    SERUM  339 

relapses  being  infrequent — us  if  the  organisii),  when  it  had 
once  been  assisted  to  defend  itself  against  the  tubercular 
parasite,  were  able  to  continue  the  struggle  successfully  for 
the  future.  The  amount  of  complement  present  in  the 
blood  is  said  to  be  increased,  and  the  antitoxic  power  is 
distinctly  raised.  This  is  not  a  mere  passive  immunity,  due 
to  the  actual  doses  of  antitoxin  administered,  as  the  in- 
crease is  much  greater  than  can  be  thus  accounted  for. 
On  the  other  hand,  Mircoli  considers  that  the  use  of 
tuberculin  adds  to  the  amount  of  toxin  present  in  the 
blood,  and  may  actually  overthrow  an  existing  balance 
of  immunity  and  cause  the  patient  to  succumb  to  the 
disease,  which  otherwise  he  might  have  successfully 
resisted. 

Most  other  observers  who  have  tried  Maragliano's  serum 
for  the  treatment  of  tuberculosis  have  failed  to  produce 
any  marked  improvement  by  its  means. 

Marmorek's  serum.  —  Marmorek1  claims  to  have 
isolated  from  the  B.  tuberculosis  a  special  toxin,  differing 
from  tuberculin  (this  he  considers  only  a  subsidiary  sub- 
stance which  aids  in  the  production  of  the  true  poison),  and 
by  the  inoculation  of  this  toxin  in  horses  has  prepared  a 
serum  which  acts  as  a  protective  to  animals  against  tuber- 
cular infection.  Marmorek  has  used  the  serum  in  cases  of 
pulmonary  tuberculosis  and  tubercular  pleurisy,  and  claims 
good  effects.  He  has  also  used  it  in  tubercular  meningitis, 
with  some  amelioration  of  symptoms,  and  thinks  that 
it  might  prove  curative  of  this  condition  if  used  early 
enough.  The  serum  has  been  tried  by  a  large  number  of 
observers  with  divergent  results.  Thus  Ullmann  -  speaks 
of  the  serum  as  a  specific  remedy,  superior  to  all  other 
methods  of  treatment,  and  Monod,3  Baer,1  Schenker,5 

1  See  Lancet,  1903,  ii.  1470. 

1  Wien.  Min.  Woch.,  1906,  No.  22. 

1  Compt.  Rend.  Acad.  Mi-d.,  Jan.,  1907. 

4  Munch,  med.  iroek.,  1907,  No.  24,  p.  1670. 

8  Ibid.,  1907,  p.  2125. 


340       SERUMS,    VACCINES,    AND   TOXINS 

Roever,1  and  Thieme,2  to  quote  only  a  few  writers,  are 
favourably  impressed  with  its  value.  Glaessner :>>  and 
Hoffa 4  found  the  remedy  useful  in  surgical  tuberculosis 
(joints,  l>ones,  etc.),  and  van  Huellen  '  in  abscesses  and 
peritonitis.  On  the  other  hand,  Kraus  c  and  Mann  "<  found 
the  serum  useless  in  cases  of  pulmonary  tuberculosis,  and 
Stadelinann  and  Benfey  s  and  Krokiewicz  and  Englander  a 
believe  it  to  be  actually  harmful. 

Bosanquet  and  French 10  observed  a  rise  in  the  opsonic 
index  after  rectal  injections  of  the  serum,  but  no  improve- 
ment in  the  clinical  features  of  their  cases.  In  one  instance 
in  which  the  serum  was  administered  subcutaneously  a 
rapid  fall  in  the  opsonic  index  occurred,  and  the  patient 
appeared  to  be  harmed  rather  than  benefited.  This  would 
seem  to  suggest  that  the  serum  contains  some  toxic  body 
allied  to  tuberculin,  rather  than  an  antitoxin. 

The  evidence  is  at  present  too  conflicting  to  allow  a 
definite  conclusion  to  be  formulated  as  to  the  value  of  the 
serum.  It  would  seem  to  merit  further  trial  in  cases  of 
surgical  tuberculosis,  but  it  has  proved  disappointing  in 
pulmonary  disease.  Rectal  administration  of  the  serum 
(5  c.c.  daily)  is  to  be  preferred  to  the  hypodermic  method, 
but  is  disliked  by  patients.  If  the  hypodermic  method  is 
employed,  the  doses  should  be  smaller  and  the  intervals 
between  them  longer. 

Other  serums. — Nicholls  prepared  an  antitoxic  serum 
by  injecting  goats  with  Koch's  new  tuberculin  (T.R.). 

1  Beitr.  :.  Klin.  d.  Tuberk.,  May  26,  1906. 

-  Deut.  med.  Woch.,  1908.  No.  29. 

3  Ibid.,  No.  16. 

4  BerL  klin.  Woch.,  1906,  No.  44. 

5  Deut.  Zeitschr.f.  Chir.,  1906,  Xos.  1-3. 

6  Zeitschr.f.  Tuberk.,  1905,  vii.,  Hft.  3. 
'  Wien.  klin.  Woch.,  1906,  No.  1'J. 

8  Berl.  klin.  Woch.,  1906,  93. 

9  Wien.  klin.    Woch.,  1906,  No.  11.      (For  further  literature  see 
Catz,  Progres  Medical,  1908,  No.  26.) 

»«  Brit.  Med.  Jvurn.,  1907,  i.  862. 


SERUM  TREATMENT  OF  TUBERCULOSIS    341 

The  injections  were  given  subcutaneously  in  the  neck, 
once  a  week,  starting  with  doses  of  0-0025  mg.,  and  rising 
gradually  to  15  mg.  by  the  end  of  seven  months.  The 
serum  thus  prepared  seemed  to  have  some  restraining 
power  over  the  development  of  the  disease  in  rabbits  and 
guineapigs,  but  it  could  not  be  called  curative. 

Macfarland1  injected  an  ass  with  tuberculin,  and  tried 
the  serum  obtained  from  it  in  15  cases  of  tuberculosis,  but 
without  definite  results. 

Di  Capra2  finds  diphtherial  antitoxin  useful  in  pul- 
monary tuberculosis.  He  states  that  under  its  influence 
fever  diminishes,  cough  is  relieved,  and  appetite  improves 
(see  also  Normal  Horse  Serum,  p.  234). 

On  the  whole,  we  have  to  confess  that  at  present  it  has 
not  been  found  possible  to  produce  a  serum  which  will 
influence  tuberculosis  to  an  extent  at  all  comparable  with 
the  effects  of  antitoxin  in  diphtheria.  This  want  of  success 
is  probably  owing  to  our  inability  to  prepare  an  adequately 
strong  solution  of  toxins  of  the  tubercle  bacillus.  Mucli 
of  the  toxic  matter  of  this  organism  seems  to  remain  iritra- 
cellular,  and  not  to  be  given  off'  into  the  culture-medium. 
The  last  word  has  not  yet  been  said  on  the  matter,  and  it 
is  possible  that  more  success  will  be  obtained  by  further 
trials ;  but  it  is  not  in  this  direction  that  our  hopes  of 
combating  the  disease  seem,  at  pi'esent,  to  point. 

IMMUN   KORPER   (I.E.) 

Spengler3  has  devised  an  immunizing  preparation  to 
which  he  gives  the  name  "I.K."  (Immun  Korper).  It 
is  prepared  from  the  red  corpuscles  of  immunized  animals, 
in  which  he  believes  the  protective  substances  to  be 
formed,  and  is  administered  hypodermically  or  by  rubbing 
into  the  skin.  It  produces,  according  to  its  inventor's 
statement,  improvement  in  breathing  and  in  subjective 

1  Journ.  Amer.  Med.  Assoc.,  1897,  ii.  359. 

2  Giorn.  Internaz.  dette  Sci.  Med.,  1903,  No.  2. 

3  Deut.  med.  Woch.y  1908,  No.  38k 


342       SERUMS,    VACCINES,    AND    TOXINS 

symptoms,  and  a  disappearance  of  bacilli  from  the  sputum. 
It  can  also  be  used  for  diagnostic  purposes,  as  it  produces  a 
local  reaction  around  tubercular  lesions. 

The  majority  of  writers  who  have  tried  this  preparation 
regard  it  as  useless  (Kapilowsky,1  Roth,2  Schaefer,3  Baer  4), 
but  it  is  recommended  by  a  few,  such  as  Porter,  :>  Hallos,6 
and  Armstrong.7  This  last  author  describes  the  pre- 
paration as  a  clear,  colourless  liquid,  with  an  acid  reaction 
and  a  sp.  gr.  of  1004  ;  it  does  not  give  a  precipitate  on 
boiling,  but  forms  a  ring  with  nitric  acid  and  a  precipitate 
with  Millon's  reagent.  It  is  both  lytic  and  antitoxic,  and 
may  exert  a  protective  action  in  a  dilution  of  1  in  1,000 
billion.  Credat  Judarus  ! 

COXTRATOXIN 

A  substance  called  "  Contratoxin,"  prepared  by 
Mehnarto,  is  said  to  consist  of  "various  animal  plasmas,'' 
including  that  of  the  lobster.  It  is  recommended  by  the 
inventor  for  tuberculosis,  as  having  a  lytic  action  on  tubercle 
bacilli  as  well  as  on  staphylococci  and  streptococci.  It  was 
tried  at  Brompton  Hospital  by  Dr.  J.  J.  Perkins  and 
Dr.  A.  C.  Inman  ;  8  no  good  results  were  obtained.  As  the 
composition  of  the  remedy  is  secret,  its  use  is  forbidden 
by  the  well-known  professional  rule,  while  its  apparent 
ineffectiveness  leaves  no  excuse  for  violating  this  canon. 

ANTISTREPTOCOCCIC  SERUM  IN  TUBERCULOSIS 
It  has  already  been  pointed  out  that  much  of  the  de- 
struction of  the  pulmonary  tissue  which  takes  place  in  cases 


1  Abgtr.  in  Zeittclir.f.  Immunit(it*fi>r*i-li.,  11HO,  p. 
«  Ifiinch.  med.  Woch.,  1910.  p.  2'.M;S 
»  Zeitsclir.f.  Tuberk.,  1910,  xvi.,  lift.  1. 
*  Btrl.  Tdin.  Jl'.-rJt..  11U2,  p.  208. 
s  Med.  Record,,  1911,  bcxx.  349. 
6  Virrh.  Arch.,  1913,  ccxiii.  3*". 
'  '-J.K.  Therapy."     1'.'14. 

8  Personal  communication  .     We  have  not  been  able  to  find  any 
literature  on  the  subject. 


TUBERCULOSIS  343 

of  phthisis  is  due  to  a  secondary  infection  of  ulcerated 
surfaces  by  pyogenic  bacteria,  especially  streptococci.  The 
attempt  has  been  made  to  combat  these  invaders  by  the  use 
of  antistreptococcic  serum.  Some  results  of  this  method  of 
treatment  are  recorded  by  Bonney.1  He  selected  cases  in 
which  large  numbers  of  streptococci  were  to  be  found  in  the 
sputum.  Other  signs  of  infection  with  these  organisms 
are  to  be  seen  in  the  occurrence  of  chills  or  irregular 
oscillation  of  the  temperature,  or  in  profuse  sweating  at 
night.  Bonney  used  the  serum  in  26  cases,  all  of  which 
were  in  an  advanced  stage  of  the  disease  and  had  failed  to 
benefit  by  oi'dinary  methods  of  treatment.  As  a  result, 
3  cases  were  apparently  cured,  and  4  others  were  set 
well  on  the  way  to  recovery.  Five  cases 'improved  dis- 
tinctly, but  not  sufficiently  to  render  recovery  more  than 
problematical ;  while  8  others  exhibited  temporary  ame- 
lioration of  symptoms,  but  the  course  of  the  disease  was 
not  checked.  In  6  cases  no  definite  results  were  obtained. 
Menzer 2  has  also  obtained  good  results  with  his  serum  in 
these  cases,  and  considers  "that  the  inflammatory  reaction 
which  occurs,  due  to  its  action,  may  have  a  beneficial  effect  on 
the  tubercular  lesions,  besides  combating  the  streptococci. 

GENERAL  CONCLUSIONS 

(1)  Tuberculin. — A.  The  original  tuberculin  affords 
a  valuable  means  of  diagnosis  when  inoculated  cutaneously 
or  injected  hypodermically.  It  is  not  infallible,  the  margin 
of  error  amounting  to  about  10  per  cent.  Calmette's 
modification  of  the  original  tuberculin  is  particularly  use- 
ful as  a  diagnostic  agent.  It  should  not  be  used  indis- 
criminately, but  only  in  cases  in  which  other  means  of 
diagnosis  have  been  tried  and  failed,  and  in  which  the 
question  of  the  existence  of  tuberculosis  is  of  immediate 
importance  to  the  patient. 

1   Med.  News,  July  13,  1903. 

-  Munch,  med.  JFoch.,  Oct.  27,  1903,  p.  1877. 


344       SERUMS,    VACCINES,    AND    TOXINS 

This  form  of  tuberculin  should  not  be  used  therapeutic- 
ally,  except  perhaps  in  lupus. 

B.  The  new  tubercidin  (T.R.)  is  of  considerable  value  in 
the  treatment  of  some  cases  of  lupus  vulgaris,  especially 
those  in  which  the  disease  has  involved  parts  inaccessible  to 
direct  surgical  or  photo-therapeutic  measures.  It  may  do 
good  also  in  some  cases  of  laryngeal  tuberculosis.  The  best 
results  from  its  use  are  obtained  in  tuberculosis  of  the 
genito-urinary  tract,  of  the  peritoneum,  of  the  eye,  and  of 
bones  and  joints.  Early  tuberculous  adenitis  also  yields 
to  tuberculin  T.R.,  but  enlarged  glands  of  old  standing  do 
not  undergo  any  marked  alteration.  It  is  contraindicated 
in  tubercular  meningitis. 

This  form  of  tuberculin  may  perhaps  be  of  value  in 
selected  cases  of  pulmonary  tuberculosis.  It  should  be  used, 
if  at  all,  along  with  ordinary  treatment  by  open  air  and 
increased  feeding  in  patients  who  are  practically  free  from 
fever,  especially  in  cases  which  appear  to  be  making  little 
progress  by  hygienic  measures  alone. 

(2)  Agglutination  test. — This   method    of  diagnosis, 
as  at  present  carried  out,  is  complicated    and    unreliable. 
It  is  of  no  practical  value  for  the  diagnosis  of  phthisis.     It 
may,  perhaps,  be  of  use  for  distinguishing  between  tubercular 
ascites  and  other  collections  of  fluid  in  the  abdomen. 

(3)  Serum  treatment. — A.  Treatment  of  tuberculosis 
by  the  serum  of  immunized  animals  is  at  present  unsatisfac- 
tory.    Maragliano's  and  Marmorek's  serums  may  possibly 
be  of  some  use,  but  the  evidence  is  not  conclusive. 

B.  In  cases  of  pulmonary  tuberculosis  accompanied  by 
the  presence  of  large  quantities  of  streptococci  in  the  sputum, 
treatment  with  antistreptococcic  serum  appears  to  have 
given  good  results,  and  is  certainly  worthy  of  trial. 

(4)  Protective  vaccination. — It  is  possible  to  render 
animals  immune  to  tuberculosis  by  vaccination  with  attenu- 
ated bacilli.     As  to  the  announcement  by  Maragliano,  and 
by  von  Behring  and  others,  of  a  means  of  vaccinating  human 
beings  against  the  disease,  no  sufficient  data  are  available. 


CHAPTER  XVII 
LEPROSY;     STREPTOTRICHOSIS ;     RINGWORM 

LEPROSY 

Etiology. — The  Bacillus  leprce.  was  discovered  by  Han- 
sen  in  1886.  Attempts  to  cultivate  it  artificially  have 
generally  failed,  but  one  or  two  successful  cultures  have 
been  reported.  The  lower  animals  appear  to  be  insusceptible 
to  this  organism. 

Complement-fixation. — Biehlen  and  Eliasberg ]  state 
that  they  obtained  fixation  of  complement  with  the  serum  of 
lepers,  using  as  antigen  a  solution  of  leprous  nodules  in 
antiformin.  Duval 2  makes  a  similar  statement,  his  antigen 
being  a  culture  of  the  bacillus ;  but  assertions  as  to 
the  cultivation  of  B.  leprcv  are  to  be  received  with 
caution. 

Serum  treatment. — Carrasquilla3  endeavoured  to  pre- 
pare an  antidotal  serum  by  injecting  the  blood  of  lepers 
into  asses  and  young  horses.  The  resulting  serum  is  prob- 
ably quite  inert.  Sugai,  Mabuchi,  and  Mononobe  4  prepared 
a  serum  by  injecting  goats  with  an  emulsion  of  leprous 
tissue.  They  believed  that  they  saw  beneficial  results  in 
patients  treated  with  this  serum,  the  rash  diminishing  and 
nodules  softening.  • 

Non-specific  treatment. — Attempts  have  been  made 
to  treat  the  disease  with  antivenene,  and  good  results  are 

1  Lepra  Bib.  Internat.,  1910,  ix.  207. 

2  Med.  Record,  1911,  Ixxix.  177. 
s  Dent.  med.  WocU.,  1397. 

4  Abstr.  in  Zcltuchv.f.  TmmunitdtsforscJi.,  1910,  p.  1157. 
345 


346       SERUMS,    VACCINES,    AND    TOXINS 

claimed  for  this  method  by  Dyer '  (5  cases ;  2  cured,  3 
improved).  Injections  of  tuberculin  have  also  been  tried* 
and  have  apparently  resulted  in  some  softening  of  leprous 
nodules,  but  no  permanent  good  has  been  effected. 
Abraham-  states  that  "fresh  nodules  ci'op  up,  and  the 
patients  are  generally  no  better  off  after  treatment  than 
before."  The  disease  runs  a  very  chronic  course,  with 
intervals  of  impi'ovement  or  cessation  of  advance.  Hence 
many  remedies  have  been  advocated  as  cures,  the  natural 
remissions  being  attributed  to  their  action.  There  is,  unfor- 
tunately, no  greater  reason  to  think  that  any  serum  is  a 
reliable  remedy  than  to  believe  in  the  methods  of  drug 
treatment  which  have  been  advocated. 

Vaccine  treatment. — Deycke  and  Reschad  *  isolated 
a  streptotlmx  from  cases  of  leprosy  and  used  it  as  a  vaccine  : 
they  observed  good  results.  They  have  also  separated  from 
the  organisms  a  fatty  substance  to  which  they  give  the 
name  of  "  iiastin " ;  this  they  use  in  the  form  of  an  oily 
solution  for  injection.  They  suggest  that  it  might  also  be 
of  use  in  tuberculosis.  Different  strengths  are  obtainable, 
labelled  BO,  B 1,  B  2.  Perper,  using  the  two  stronger 
solutions,  claims  that  he  cured  2  cases  out  of  5  treated. 
Kupfter4  reported  very  favourably  on  the  results  obtained 
from  the  use  of  this  agent,  although  in  many  of  his  cases 
cliaulmoogra  oil  was  also  administered.  At  a  discussion 
at  the  International  Leprosy  Congress,  1 909,  very  different 
views  were  expressed  as  to  the  value  of  nastin,  and  we  are 
not  inclined  on  theoretical  grounds  to  regard  it  as  a  likely 
specific  for  the  disease. 

For   reasons   we   have   already    given   we   venture   to 
express  some  scepticism  'as  to  the  claim  of  Roos5  to  have 

1  New  Orleans  Med.  and  Surg.  Journ.,  Oct.,  1897. 
'-'  Art.      "  Leprosy,"     in     Allbutt's     "  System     of     Medicine.'' 
ii.   78. 

3  Deut.  mcd.  Woch.,  1907,  p.  89. 

*  Lepra  Bib.  Internat.,  1909,  viii.,  Part  3. 

5  Ibid.,  1912.  xii.  125. 


STREPTOTKICHOSIS— RINGWORM         347 

benefited  12  cases  of   leprosy  by  the  use  of  a  vaccine  of 

B.  leprce. 

STREPTOTRICHOSIS 

Wynn  *  has  recorded  a  case  of  actinomycosis  of  the  lung 
successfully  treated  with  a  vaccine.  The  patient  was  a 
boy  of  14  years,  and  the  dose  used  was  O001  mg.  of  the 
solid  substance  of  the  organism  isolated  from  the  pus  and 
grown  on  agar  ("  actinomycotin  ").  The  authors  also  have 
had  very  satisfactory  results  in  a  series  of  cases  not  yet 
recorded. 

Agglutination  test. — Widal  and  Abrami2  found  in 
cases  of  sporotrichosis  that  the  spores  (not  the  mycelium) 
of  the  fungus  Sporoirichum  beurmanni  were  agglutinated 
by  the  patient's  serum,  but  that  this  reaction  was  not 
strictly  specific,  a  "group  reaction"  occurring  with  serum 
of  patients  suffering  from  actinomycosis  or  from  thrush, 
though  not  with  that  derived  from  cases  of  tinea  or  favus. 
This  agglutination  reaction  with  sporotrichial  spores  has 
been  used  for  the  diagnosis  of  actinomycosis,  the  reaction 
occurring  in  dilutions  of  1  :  30,  or  even  1  :  300. 

RINGWORM 

Bruck  and  Kusonoki,3  who  cultivated  the  trichophyton 
fungus  on  a  special  medium,  filtered  and  sterilized  the 
liquid,  and  put  it  up  for  use  with  a  little  phenol  as  a  preserva- 
tive. They  first  employed  this  so-called  "  trichophytin  "  as 
a  diagnostic  test,  as  it  may  give  a  reaction,  analogous  to  the 
tuberculin  reaction,  when  injected  into  patients  affected 
with  ringworm.  They  found  also  that  it  had  some  curative 
effect.  Stein  4  finds  it  useful  in  kerion  and  sycosis,  the  best 
species  of  the  hyphomycetes  for  such  use  being  Ackorion 

1  Brit.  Med.  Journ.,  1908,  i.  554. 

2  Widal  and  Abrami,   Semaine  Med.,   1908,  p.  309  ;    Gorgon  and 
Gougliot,  ibid.,  1910,  p.  117;   Widal,  ibid.,  1910,  p.  238;  Jeanselme, 
ibid.,  1910,  p.  308. 

3  Dent,  med   Woch.,  June  15,  1911. 

4  Wien.  klin.  Woch.,  1912,  p.  1817. 


348       SERUMS,    VACCINES,   AND   TOXINS 

quinckeanum.  He  also  uses  an  ointment  of  trichophytin 
for  superficial  cases  which  fail  to  give  a  reaction  to 
hypodermic  injections.  Lombardo l  finds  that  trichophyton 
extracts  are  of  no  value  in  the  treatment  of  chronic  cases 
of  ringworm. 

1  Giorn.  Ital.  d.  Mai.  Yen.,  1912,  liii.,  No.  2. 


CHAPTER    XVIII 
AFFECTIONS    DUE   TO   STREPTOCOCCI 

STREPTOCOCCIC    SEPTICAEMIA,    RHEUMATISM, 
CHOREA,    SCARLATINA 

Nature  Of  the  Organisms.  —  Much  controversy  has 
centred  round  the  question  of  the  identity  or  diversity 
of  the  streptococci  found  in  different  conditions.  Some 
writers l  have  enumerated  eighteen  different  (?)  species. 
An  attempt  was  at  one  time  made  to  differentiate  them 
into  "  short"  and  "long"  varieties,  viz.  those  which  formed 
chains  consisting  of  a  large  number  of  separate  cocci,  and 
those  which  occurred  in  smaller  groups ;  but  this  classi- 
fication is  untenable,  as  the  same  coccus  may  form  short  or 
long  chains  according  to  the  circumstances  of  its  environ- 
ment. Within  the  body  of  an  infected  animal  these  organ- 
isms generally  occur  in  pairs,  or  as  separate  units,  only 
showing  chain-formation  in  artificial  media.  On  the  other 
hand,  the  pneumococcus  (Diplococcus  pneumonias)  frequently 
takes  the  form  of  chains  of  cocci  when  grown  outside  the 
body.  There  appears  to  be  no  essential  difference  with 
regard  to  chain-formation  between  streptococci  and  many 
so-called  diplococci. 

Many  observers  hold  that  all  the  streptococci  found 
in  different  pathological  conditions  are  in  reality  the 
same  organism,  modified  in  some  of  its  characteristics 
by  circumstances.  A  strong  upholder  of  this  view  is 
Marmorek,3  who  has  examined  organisms  derived  from 

1  Andrewes  and  Border,  Lancet,  1906,  i.  1245. 
-  Ann.  dc  Vlnst.  Pasteur,  March,  1902,  et  passim, 
349 


350       SERUMS,    VACCINES,    AND    TOXINS 

erysipelas,  puerperal  fever,  scarlatina,  pustules  and  boils, 
and  sore  throats,  and  finds  that  all  of  them  produce  the 
same  poison,  and  that  all  are  antagonized  by  an  antitoxic 
serum  prepared  from  cultures  of  any  one  of  them.  Aron- 
son T  is  of  the  same  opinion  ;  he  finds  that  a  horse 
immunized  against  one  variety  is  resistant  to  all. 

On  the  other  hand,  Meyer,2  using  the  method  of  agglu- 
tination, believes  that  there  are  two  different  species  :  (1) 
the  pyogenic  organism,  met  with  in  erysipelas,  suppuration, 
etc. ;  and  (2)  a  streptococcus  met  with  in  cases  of  angina 
(sore  throat).  Andre wes  and  Horder3  distinguished  five 
different  species,  and  Foulerton1  also  believes  in  the  exist- 
ence of  more  than  one  species,  these  writers  basing  their 
views  upon  the  changes  produced  in  solutions  of  various 
carbohydrates. 

At  present  the  question  of  the  unity  or  diversity  of 
the  streptococci  cannot  be  answered  with  certainty.  It  is 
clearly  of  the  greatest  importance.  For  the  moment  we 
have  these  two  clinical  facts  strongly  before  us — viz.  that 
since  the  introduction  of  "  polyvalent "  antistreptococcic 
serum  there  has  been  a  marked  improvement  in  therapeutic 
value,  and  further,  that  frequently,  when  the  serum  prepared 
by  one  manufacturer  has  proved  entirely  without  effect, 
the  employment  of  antistreptococcic  serum  from  another 
maker  has  been  immediately  followed  by  a  complete 
amelioration  of  the  patient's  condition.  It  seems  difficult  to 
believe  that  the  pneumococcus,  which  has,  besides  other 
peculiarities,  the  property  of  forming  a  capsule,  is  not  a 
separate  species  of  organism.  Other  diseases  in  which 
chain-cocci  have  been  met  with  are  rheumatism,  chorea, 
and  scarlatina.  We  may  consider  the  questions  of  serum 
treatment  connected  with  these  organisms  under  the  follow- 

1  Deut.  med.  Woch.,  1903,  June  18,  p.  439. 

2  Ibid.,    1902,   No.   42.      For  experiments    on    agglutination   of 
streptococci,  see  also  Zelenski,  Wien.  klin.   Woch.,  1904,  p.  406. 

8  Iioc.  cit. 

4  Lancet,  1904,  ii.  1828. 


SEPTICAEMIA    AND    ERYSIPELAS         351 

ing  heads  :  (1)  Septicaemia  and  Erysipelas  ;  (2)  Rheumatism  ; 
(3)  Scarlatina. 

1.  SEPTICAEMIA  AND   ERYSIPELAS 

StreptOCOCCUS  pyogenes.  —  This  organism  was  first 
observed  by  Ogston  in  1881,  and  described  by  Rosenbach  in 
1884.  It  has  been  found  in  cases  of  spreading  cellulitis 
and  pyaemia,  in  some  instances  of  malignant  endocarditis,  in 
puerperal  sepsis,  in  erysipelas,  in  the  pyogenic  affections 
complicating  acute  infectious  diseases  (small-pox,  enteric 
fever,  etc.),  in  some  membranous  sore-throats,  in  a  variety 
of  intestinal  lesions,  and  in  the  cutaneous  affections  known 
as  ecthyma  and  impetigo  contagiosa.  Marmorek  l  has  pre- 
pared a  special  medium  for  growing  streptococci,  consisting 
of  ordinary  broth,  peptonized  meat,  leucine,  and  glycocol. 
He  has  also  grown  them  in  a  mixture  of  broth  and  human 
serum,  and  in  broth  mixed  with  serous  fluid  from  the 
pleura  or  peritoneum.  By  cultivating  them  in  this  way 
and  alternately  passing  them  through  rabbits  he  has 
succeeded  in  producing  bacteria  of  such  virulence  that 
0-00000000001  c.c.  of  the  culture  will  inevitably  kill  a 
rabbit.  This  quantity  is  calculated  to  contain,  on  an 
average,  one  single  streptococcus. 

If  any  pathogenic  streptococcus  is  grown  in  a  fluid 
medium  until  growth  ceases,  no  other  strain  of  these 
organisms  will  subsequently  flourish  in  that  fluid  without 
addition  of  further  nutrient  material.  This  test  is  used 
by  Marmorek  to  prove  the  identity  of  all  the  streptococci. 

Toxins.  —  Marmorek  finds  that  all  streptococci,  what- 
ever their  origin,  manufacture  the  same  toxin.  It  is  of 
the  nature  of  a  diastase,  and  its  activity  is  destroyed  at  a 
temperature  of  70°  C.  In  addition  to  the  diastatic  ferment, 
streptococci  give  rise  to  a  poisonous  substance  which  has 
haemolytic  powers  ;  this  has  Jbeen  called  "  streptocolysin," 
and  is  said  to  possess  a  toxophore  and  a  haptophore  group.2 

1  Ann.  de  Vlnst.  Pasteur,  1895,  ix.  593  ;  also  1902,  xvi.  169. 

2  Ruediger,  Journ.  of  the  Amer.  Met!.  Assoc.,  Oct.  17,  1903. 

Lll3K/,UY 


'LLiE(>iE  or 


352       SERUMS,   VACCINES,    AND   TOXINS 

It  is  destroyed  at  a  temperature  of  70°  C.  Its  presence 
accounts  for  the  petechial  eruptions,  and  perhaps  for  the 
jaundice,  so  often  met  with  in  septic  conditions. 


AXTISTREPTOCOCCIC 

The  serum  originally  introduced  by  Marniorek  was 
prepared  by  inoculating  horses  with  the  virulent  organisms 
obtained  in  the  way  previously  recorded.  Living  cultures 
are  more  efficacious  in  the  formation  of  a  potent  serum  than 
are  dead  organisms.  Very  small  doses  are  used  for  the  first 
injections,  which  are  gradually  raised  as  the  animal  becomes 
more  resistant  :  the  final  dose  may  reach  GOO  c.c.  of  a  virulent 
culture.  The  process  extends  over  a  year.  Each  injection 
must  be  sufficient  to  produce  a  distinct  reaction  ;  and  the 
blood  of  the  horse  is  withdrawn  four  weeks  after  the  last 
injection.  Marmorek  finds  that  it  is  impossible  to  produce 
an  effective  serum  by  means  of  the  toxins  of  the  cocci 
alone  ;  apparently  these,  as  obtained  in  artificial  media,  are 
not  strong  enough.  He  considers  that  his  serum  lias  a 
weak  antitoxic  power  ;  it  is  chiefly  bactericidal.  Raw,1  on 
the  other  hand,  maintains  that  the  Paris  serum  is  mainly 
antitoxic. 

Many  authorities,  however,  hold  that  the  passage  of 
streptococci  through  animals  reduces  their  virulence  for 
man,  and  that  a  fundamental  error  is  inherent  in  Marmoivk's 
method  of  preparing  his  serum.  Of  the  different  brands 
of  serum  now  in  use,  those  of  Marmorek  and  Denys  are 
made  from  organisms  passed  through  animals,  and  those 
of  Tavel,  Krumbein,  Moser  and  Memer  from  strepto- 
cocci derived  from  human  sources.  Aronson  combines 
both  kinds.  Experiments  by  Meyer  and  by  Sommerfeld 
appear  to  show  that  of  these  serums  Aronson's  is  the  most 
etfective.- 

Value  of  antistreptococcic  serum.—  A  few  general 

1  Lancet,  1898,  ii. 

2  Zeitschr.f.  klin.  Med.,  1900;   Centralbl.  /.  Jiakt.,  I.  Ori-j.,  1903, 
xxxiii.  722. 


353 


considerations  as  to  the  use  of  antistreptococcic  serum  may 
be  set  out  at  this  point.  In  the  first  place,  it  must  be  re- 
membered that  cases  of  infection  with  pyogenic  organisms 
differ  from  one  another  in  severity  almost  more  than  do 
attacks  of  any  other  kind  of  disease.  It  is,  therefore, 
practically  impossible  to  form  any  estimate  of  the  mortality 
of  such  cases  from  statistics,  and  equally  impracticable  to 
apply  the  statistical  method  to  recorded  cases  of  cure  or 
failure.  In  cases  which  appear  hopeless,  recovery  may 
take  place  in  a  most  marvellous  manner  without  the  use  of 
any  specific  remedy.  If  such  a  "  cure  "  is  effected  in  a  case 
treated  with  serum,  there  is  naturally  a  tendency  to  ascribe 
the  good  result  to  the  serum.  On  the  other  hand,  there  are 
many  instances  in  which  the  infection  is  so  intense  and  so 
rapid  in  its  onset  that  it  would  be  hopeless  to  expect  any 
antibacterial  serum  to  prove  efficacious.  Thus  only  a  very 
large  collection  of  cases  would  serve  as  a  basis  for  statistical 
calculation,  and  this  the  nature  of  the  disease  makes  it 
specially  difficult  to  procure,  as  most  instances  of  invasion 
by  pyogenic  organisms  may  be  described  as  "  accidental  "  ; 
that  is  to  say,  they  are  sporadic  in  occurrence  and  due  to 
inoculation  of  cocci  in  wounds,  etc.,  while  the  state  of  health 
of  the  individual  attacked  appears  to  play  a  greater  part 
in  the  process  than  in  most  other  diseases.  We  are  thus 
deprived  of  the  aid  afforded  by  the  epidemic  occurrence  of 
disease,  in  which  large  numbers  of  cases  are  met  with  under 
very  similar  circumstances,  are  often  treated  in  special  hos- 
pitals, and  are  readily  adapted  for  collection  and  tabulation. 
Finally,  many  of  the  series  of  cases  reported  are  of  a  very 
heterogeneous  nature,  embracing,  for  example,  puerperal 
fever,  erysipelas,  and  cellulitis,  the  writer  applying  the 
results  obtained,  in  all  of  these  together  to  establish  the 
value  of  the  serum  in  a  general  way.  It  will  be  best  briefly 
to  consider  the  opinions  that  have  been  expressed  as  to 
serum  treatment  in  each  of  these  conditions  separately. 

The  exact  mode  of  action  of  antistreptococcic  serum  is 
not   satisfactorily   determined.     It  is  not  bacteriolytic  in 
x 


354       SERUMS,    VACCINES,    AND    TOXINS 

vitro.  Menzer l  believes  that  it  acts  by  inducing  phago- 
cytosis (opsonically),  but  Reisch  -  denies  this  in  the  case  of 
Aronson's  serum. 

Puerperal  fever. — A  special  committee  was  appointed 
by  the  American  Gynaecological  Society  to  consider  the 
value  of  antistreptococcic  serum  in  puerperal  sepsis.  The 
committee  reported  3  that  they  had  collected  records  of  352 
cases  treated  with  serum,  among  which  the  mortality  was 
20-74  per  cent.,  whereas  among  all  cases  of  the  disease  not 
so  treated  the  total  death-rate  worked  out  at  5  per  cent. 
It  would  seem  on  the  face  of  this  report  that  the  committee 
must  have  concluded  that  the  use  of  the  serum  had  in- 
creased the  mortality  of  puerperal  fever  by  about  15  per 
cent. — a  fair  instance  of  proving  too  much,  since  no  one  can 
reasonably  maintain  ihat  deleterious  effects  are  often  due 
to  the  serum,  and  this  the  committee  themselves  admitted  ; 
the  most  that  can  be  said  against  it  is  that  it  is  ineffectual. 
Hence  the  only  conclusion  that  can  be  fairly  drawn  from 
the  above  figures  is  that  the  statistical  method  is  untrust- 
worthy in  this  instance.  The  report  of  the  committee  is 
valuable  as  affording  a  very  complete  bibliography  of  cases 
recorded  up  to  the  time  of  its  appearance. 

Savor4  records  his  results  in  16  cases:  in  6  no  good 
effects  were  seen,  in  5  the  value  of  the  remedy  was  doubtful, 
in  the  remaining  5  good  results  were  obtained. 

Blumberg5  tried  the  serum  in  12  cases,  all  of  them 
severe,  in  9  of  which  a  bacteriological  examination  was 
made  of  the  lochia.  Two  cases  showed  anaerobic  diplo- 
cocci ;  no  good  effects  from  serum.  Four  cases  showed 
mixed  infection,  some  streptococci  :  two  died,  one  improved 
after  injection.  Two  cases  showed  sterile  lochia ;  both 

1  Jfiiiich.  meet.  Woclt.,  Juno  23  and  30,  1903.  Cf.  Zangemeister, 
Deut.  med.  Woch.,  July  b,  1906. 

*  Abstr.  in  Centralbl.  f.  Jiakt.,  I.  Ref.,  1906,  xxxviii.  72. 

*  American  Journ.  of  Obstetrics,  1899,  xl. 
4  Quoted  by  Blumberg  (see  below). 

6  Birlin.  kHn.  Jf'ocfi.,  1901,  Xo.  5,  p.  132. 


ANTISTREPTOCOCCIC    SERUM  355 

recovered,  a  fall  of  temperature  occurring  after  injection. 
Two  cases  showed  pure  streptococcal  infection  ;  both  of 
these  recovered.  Three  cases  (lochia  not  examined) ;  two 
showed  fall  of  temperature  after  injection  (one  already 
convalescent). 

Blumberg  is  favourably  impressed  as  to  the  value  of  the 
serum.  Peham  1  also  records  good  results  in  cases  of  pure 
streptococci^  infection  ;  in  mixed  infections  and  cases  due 
to  other  organisms  no  good  results  can  be  expected. 
Burkard  ~  treated  29  cases  of  pure  streptococcic  infection 
without  a  death.  Falkner  3  records  83  cases  with  14  deaths, 
and  thinks  the  serum  useful ;  and  Bumm  4  also  noted  favour- 
able results,  using  Aronson's  serum.  Pilcer  and  Ebersen  5 
speak  favourably  of  Marmorek's  serum  as  an  adjuvant  to 
other  methods  of  treatment;  but  McMurtry  6  believes  all 
serum  treatment  of  puerperal  septicaemia  to  be  quite  useless. 
Many  isolated  cases  of  benefit  attributed  to  the  remedy 
in  puerperal  sepsis  are  recorded,  but  on  the  whole  the 
results  seem  to  have  been  disappointing.  We  can  only 
conclude  that  further  observation  is  needed  to  establish  its 
true  position,  but  that  it  is  advisable  to  give  the  serum  a 
trial  in  cases  in  which  streptococci  are  found. 

Cutaneous  test. — Kohler7  describes  a  cutaneous  test 
for  this  condition.  A  culture  is  prepared  of  many  strains 
of  streptococci,  the  organisms  are  killed,  and  the  fluid 
filtered  off.  The  fluid  is  rubbed  into  the  skin  as  in  von 
Pirquet's  test,  and,  if  streptococci  are  present  in  the  blood, 
an  inflammatory  swelling  ensues  at  the  point  of  application, 
and  reaches  its  maximum  in  about  eight  hours.  The 
reaction  may  fail  to  appear  if  the  patient  is  in  extremis. 

1  Wien.  fcl}».  Woch.,  1904,  p.  405. 

2  Arch.f.  Gy»ak.,  Bd.  Ixxix.,  Heft  3. 

3  Wien.  MM.  Woch.,  1907,  p.  1-582. 
*  Berlin,  Min.  Woch.,  Oct.  31,  1904. 

.  5  Thtrapeut.  Monats.,  1904,  p.  509. 
6  Brit.  Med.  Journ.,  1906,  ii.  1207. 
'  Monatsh.  /.  Geburtsh.  u.  Gyntik.,  1912,  xxxv.,  Heft  2. 


356       SERUMS,    VACCINES,    AND    TOXINS 

Erysipelas. — Marmorek  states  that  lie  treated  423 
cases  of  erysipelas  with  his  serum,  with  good  results,  the 
mortality  being  3*87  per  cent.  Denys  l  reports  good  effects 
from  local  injections  of  the  serum  into  the  neighbourhood  of 
the  affected  area.  He  gives  four  injections  of  0'25  c.c.  around 
the  lesion.  Mayer  and  Michaelis,-  and  Aver,3  noted  im- 
provement in  cases  treated  with  serum ;  and  we  have 
ourselves  seen  apparently  good  results  in  a  few  instances. 

Welz*  finds  good  results  in  about  50  per  cent,  of  all 
cases  from  the  use  of  antistreptococcus  serum. 

The  serum  of  convalescents  has  been  tried  by  Fornaca, ' 
with  apparent  benefit,  but  does  not  seem  to  be  a  practicable 
remedy.  Diphtheria!  antitoxin  has  also  been  recommended. 

Cellulitis  and  septicaemia.  —  Thomas G  records  a 
series  of  15  cases  of  sepsis  successfully  treated  with  the 
serum  ;  he  administers  doses  of  30  c.c.  Good  results  are 
reported  by  Marmorek  and  others.  One  of  the  present 
writers  had  a  personal  experience  of  the  use  of  serum  in  his 
own  case,  when  he  was  suffering  from  spreading  cellulitisdue 
to  a  poisoned  post-mortem  wound.  The  subjective  effect  was 
certainly  good,  the  feeling  of  illness  and  mental  disturbance 
lessening  concomitantly  with  its  use.  The  temperature  also 
fell  gradually,  but  it  is  impossible  to  be  sure  whether  this 
was  attributable  to  the  serum  or  to  the  surgical  measures 
adopted.  In  this  case  the  serum  was  administered  in  doses 
of  10  c.c.  every  four  hours  for  several  days.  Xo  ill  effects 
were  noticeable,  but  for  some  time  after  the  injections  there 
was  very  intense  itching  at  the  sites  of  injection,  and  faint 
lines  of  pigmentation  marked  the  tracks  made  by  the 
needle. 

Ulcerative  endocarditis. — Some  good  results  have 

1  Semalne  Mid.,  1901,  p.  40. 

2  Berlin,  klin.  JTodl.,  1903,  p.  377. 
»  Med.  Record,  Aug.  26,  1905. 

4  Therapeut.  Monat*.,  1913.  p.  273. 

5  Policlin.,  July,  1905. 

6  Jourii.  of  American  Med.  As»oc.,  Feb.  18,  1899. 


ANTISTREPTOCOCCIC    SERUM 


357 


been  obtained  in  this  disease  by  the  use  of  the  serum. 
Thus,  2  cases  are  recorded  by  Mitchell  Bruce l  in  which 
apparent  cure  resulted.  In  one  of  these  a  certain  brand 
of  serum  was  found  ineffectual,  only  a  temporary  fall  of  the 
fever  being  observed;  but  on  using  a  serum  prepared  by 
a  different  maker,  permanent  improvement  was  effected. 


GHAUTS. — ILLUSTRATING  THE  EFIICACY  OF  A  SECOND  BRAND  OF 
ANTISTREPTOCOCCIC  SERUM  AFTER  FAILURE  OF  THE  FIRST. 

This  case,  which  came  under  the  notice  of  the  present 
writers  (see  Chart  3),  is  instructive  as  illustrating  one  reason 
for  the  want  of  success  which  has  often  been  experienced 
with  this  serum.  Such  failure  may  be  due,  apparently,  to 
the  existence  of  various  strains  of  the  cocci :  each  strain  gives 
rise  to  a  serum  which  is  effectual  against  that  particular 
variety,  but  which  does  not  equally  lead  to  the  destruction  of 
*  Lancet,  1898,  ii.  515. 


358       SERUMS,    VACCINES,   AND   TOXINS 

other  strains  of  streptococci  derived  from  different  sources 
(see  also  Staphylococci,  p.  383). 

Ogle  *  also  speaks  favourably  of  the  use  of  the  serum 
in  malignant  endocarditis,  and  Dyce  Duckworth  -  records 
a  case  in  which  rectal  administration  of  the  serum  appar- 
ently effected  a  cure.  Raw,3  again,  saw  good  results  from 
this  method  of  treatment,  20  c.c.  of  serum  being  given  with 
40  c.c.  of  hot  saline  solution.  Ward 4  collected  a  total 
of  25  cases,  of  which  8  were  cured  and  3  jtemporarily 
improved. 

Pernicious  anaemia. — Hunter,5  relying  on  his  discovery 
of  streptococci  in  cases  of  pernicious  anaemia,  treated  some 
patients  suffering  from  this  disease  with  antistreptococcic 
serum.  He  considered  that  good  results  were  produced. 
In  one  case  of  this  disorder,  which  was  admitted  to  Charing 
Cross  Hospital,  the  use  of  the  serum  was  followed  by 
collapse  and  death,  which  appeared  to  be  due  to  the 
injection,  and  may  have  been  analogous  to  the  few  recorded 
instances  of  death  occurring  after  diphtherial  antitoxin. 
It  was,  however,  impossible  to  be  certain  that  the  remedy 
was  actually  accountable  for  the  death  of  the  patient,  as 
pernicious  amentia  is  a  disease  which  causes  profound  de- 
generation of  the  cardiac  muscle,  and  it  is  difficult  to  be 
sure  of  the  exact  degree  of  this  myocardial  disease  in  an 
individual  case.  Sudden  death  may  occur  from  asystole  at 
any  time.  The  rapid  onset  of  delirium  and  coma  after  the 
injection  was,  however,  remarkable. 

Gangrenous  Stomatitis. — Cahall  6  reports  a  case  of 
this  affection  successfully  treated  with  the  serum.  Diph- 
therial antitoxin  may  be  useful  in  cases  of  noma  due  to 
B.  diphtherice. 

1  Lancet,  1903,  i.  720. 

2  Brit.  Med.  Jottrn.,  1903,  i.  1195. 

3  lancet,  1906,  i.  1103.    f'f.  Fenwick  and  Parkinson,  ibid.,  1244. 

4  Albany  Med.  Annals,  Oct.,  1903,  p.  515. 

5  Lanett,  1900,  i.  374. 

«  Philadelphia  Med.  Journ.,  Feb.  17,  1900, 


ANTISTREPTOCOCCIC    SERUM  359 

Purpura  haemorrhagica.—  Coutts l  has  successfully 

treated  2  cases  of  this  disease  by  rectal  injections  of  anti- 
streptococcic  serum.  He  expresses,  however,  some  doubt 
whether  normal  (horse)  serum  would  not  have  been  equally 
effective  (see  p.  434). 

The  use  of  antistreptococcic  serum  in  small-pox  and  in 
phthisis  is  alluded  to  elsewhere  (see  pp.  199  and  342). 

Local  collections  Of  pUS.— In  cases  in  which  actual 
collections  of  pus  have  formed,  the  use  of  the  serum  can  do 
no  good,  so  far  as  the  local  lesion  is  concerned.  Surgical 
measures  for  the  evacuation  of  the  pus  must  be  adopted. 
Subsequently  the  serum  may  perhaps  prevent  the  formation 
of  other  foci  of  suppuration,  or  the  death  of  the  patient  from 
septicaemia.  Menzer  considers  that,  if  pus  be  present,  the 
serum  may  even  do  mischief,  as  it  may  cause  a  breaking-up 
of  a  large  number  of  the  streptococci,  and  so  produce  an 
intoxication  of  the  whole  system  by  absorption  of  poisonous 
products.  This  is  possibly  true,  if  local  surgical  measures 
are  neglected. 

Ill  effects  Of  the  serum. — Horse's  serum  being  the 
basis  of  antistreptococcic  serum,  the  same  by-effects  may 
occur  after  its  employment  as  after  diphtherial  antitoxin, 
viz.  erythematous  and  urticarial  eruptions  and  pains  in  the 
joints.  Allusion  has  just  been  made  to  one  fatal  case  that 
was  apparently  due  to  the  serum. 

Diphtherial   antitoxin   in   septic   conditions.  — 

Diphtherial  antitoxin  has  now  been  tried  in  a  large 
number  of  different  conditions  besides  diphtheria,  and 
benefit  has  been  ascribed  to  its  use.  Paton 2  considers 
that  it  is  almost  specific  for  septic  conditions  generally.  He 
concludes  (1)  that  it  is  specific  for  all  affections  due  to 
streptococci  and  staphylococci,  and  for  simple  traumatic 
inflammations  :  (2)  that  it  acts  as  an  absorbent  for  in- 
flammatory tissues  and  for  effused  blood ;  (3)  that  it 
has  an  influence  on  the  coagulability  of  the  blood  ;  and 

1  JF.  London  Med.  Journ.,  1908,  p.  286. 

2  Australasian  Mcd,  Gaz.,  Feb.  20,  1902, 


360       SERUMS,    VACCINES,    AND   TOXINS 

that  (4)  it  acts  beneficially  in  depressed  nervous  condi- 
tions (which  may  perhaps  be  due  to  septic  or  autotoxic 
conditions). 

Paton  considers  that  the  serum  acts  well  when  it  is 
given  by  the  mouth,  and  he  adopts  this  method  of  ad- 
ministration. He  gives  the  following  formula  :  Diphtherial 
antitoxin,  3,000  units ;  trag.  carmin.,  a  sufficiency  ;  water 
to  2  ounces.  One-fourth  part  of  this  (750  units)  is  given 
night  and  morning,  or  every  four  hours.  In  erysipelas 
the  dose  is  administered  every  eight  hours.  In  acute 
peritonitis  or  perityphlitis  it  is  given  at  once,  and  repeated 
in  two  hours'  time ;  then,  again,  every  four  to  six  hours. 
The  serum  may  cause  slight  renal  irritation  or  cutaneous 
eruptions,  but  these  effects  are  unimportant. 

More  recently  Paton  appears  to  state  that  the  amount  of 
units  of  antitoxin  given  is  immaterial,  and  that  the  normal 
serum  of  the  horse  or  ox  is  almost  equally  effective  (see 
p.  434),  the  process  of  immunizing  the  animal  against 
diphtherial  toxins  only  calling  out  in  greater  amount 
some  body  always  present  in  the  animal's  serum,  which 
stimulates  the  cells  of  the  human  body  to  resist  microbial 
attack.1 

In  the  present  state  of  our  knowledge  it  appears  diffi- 
cult to  take  very  seriously  any  claims  as  to  the  value  of 
an  antitoxin  in  other  diseases  than  that  for  which  it  is 
prepared.  It  may  possibly  produce  some  leucocytosis, 
and  thus  be  beneticia',  but  it  is  at  least  as  probable  that 
the  cures  attributed  to  it  are  instances  of  the  fallacy  of 
mistaking  post  hoc  for  propter  hoc. 

Conclusions. — It  is  impossible  to  resist  the  conclusion 
that  on  the  whole  the  use  of  antistreptococcic  serum  has  been 
disappointing.  This  may  be  due  to  many  causes.  In  the  first 
place,  the  existence  of  several  strains  of  the  cocci,  which 
react  differently  to  a  given  serum,  introduces  a  constant 
source  of  failure,  especially  if  only  one  brand  of  serum  is 
available  for  use.  In  cases  which  are  sufficiently  chronic  to 
1  "New  Serumtherapy."  London,  1008, 


ANTISTREPTOCOCCIC    SERUM  361 

admit  of  the  trial  of  a  second  brand  in  the  event  of  primary 
failure,  this  course  should  be  adopted,  and  may  prove 
successful. 

In  the  second  place,  all  antibacterial  serums  appear  to 
keep  badly,  quickly  losing  their  bacteriolytic  power.  Hence 
only  freshly  prepared  serum  should  be  employed.  Many  of 
the  serums  on  the  market  have  at  one  time  or  another  been 
found  to  be  inert.  Some  of  the  disappointments  recorded  may 
have  been  due  to  neglect  to  secure  a  freshly  prepared  serum. 

Again,  many  cases  of  sepsis  are  not  due  to  strepto- 
cocci alone,  but  are  complicated  by  the  presence  of  other 
germs.  Although  the  antistreptococcic  serum  may  be 
able  to  counteract  the  former  organisms,  yet  the  others 
in  ay  have  gained  so  firm  a  footing  as  to  prove  fatal  to  the 
patient. 

Finally,  there  can  be  little  doubt  that,  until  lately, 
recourse  was  seldom  had  to  serum  treatment  till  the  disease 
was  too  far  advanced.  Owing  to  the  difficulty  of  procuring 
the  serum  and  the  expense  involved,  the  remedy  was  only 
administered  as  a  last  resource.  We  have  seen  that  in  the 
case  of  all  serums  the  most  important  condition  for  success 
is  early  use.  Now  that  a  more  plentiful  supply  of  serum  is 
obtainable,  and  the  medical  profession  is  becoming  better 
acquainted  with  the  value  of  these  remedies,  it  may  be 
hoped  that  better  results  will  be  recorded. 

We  cannot  doubt  that  in  a  certain  proportion,  at  all 
events,  of  the  cases  recorded,  the  serum  has  acted  most 
beneficially.  It  is  impossible  to  know  beforehand,  on  any 
general  grounds,  which  cases  will  react  to  the  remedy  and 
which  will  show  no  improvement.  It  would  seem,  there- 
fore, advisable,  in  all  cases  in  which  infection  by  strepto- 
cocci threatens1  to  become  generalized  (septicsernic),  to  have 
recourse  to  the  serum  at  as  early  a  stage  as  possible.  No 
harm  is  likely  to  result  in  any  case,  and  a  fatal  septicaemia 
may  be  warded  off. 

No  assistance  can  be  expected  from  antistreptococcic 
serum  in  cases  due  to  infection  by  other  pyogenic  organisms 


362       SERUMS,    VACCINES,    AND    TOXINS 

— staphylococci,  B.  pyocyaneus,  etc.  It  is,  therefore,  advis- 
able to  ascertain,  if  possible,  whether  any  individual  case  is 
clue  to  the  presence  of  streptococci,  before  using  the  serum. 
For  this  purpose  from  5  to  10  cubic  centimetres  of  blood 
should  be  withdrawn,  preferably  from  a  vein  in  the  arm,  by 
means  of  a  sterile  syringe,  and  distributed  amongst  several 
tubes  or  flasks  of  suitable  fluid  culture-medium  ;  or  the  pus 
from  any  local  lesion  which  is  available  may  be  examined 
for  the  cocci ;  or  the  streptococci  may  be  sought  for  in 
the  urine,  by  which  channel  they  are  often  excreted.  In 
cases,  however,  in  which  a  bacteriological  examination  is 
not  immediately  possible,  it  is  preferable  to  inject  the 
serum  at  once,  if  the  symptoms  are  severe  and  point  to 
streptococcic  infection,  rather  than  wait  any  considerable 
time  for  the  bacteriological  report. 

Summary  of  treatment  with  antistreptococcic 

serum. — After  adopting  such  surgical  measures  as  are 
indicated — 

1.  Inject  20  c.c.  of  polyvalent  anfcistreptococcus  serum, 
at  least  half  intravenously. 

2.  If  marked    improvement  occur,  repeat   the   dose  in 
twenty-four  hours. 

3.  If  no  obvious  improvement  be  noted,  administer  a 
similar    dose    of    polyvalent    serum    prepared    by   another 
manufacturer. 

4.  If  there  be  still  no  improvement,  try  a  third  brand. 

VACCINE  TREATMENT 

Recently,  attempts  have  been  made  to  treat  affections 
due  to  streptococci  by  means  of  vaccines  consisting  of 
dead  organisms.  It  does  not  seem  probable  that  much 
good  can  result  from  this  procedure  in  cases  of  general 
SeptiCEBITlia,  though  Sutcliffe  and  Baily l  attribute  the 
cure  of  one  such  case  to  the  use  of  a  vaccine,  the  dose  rising 
from  10,000,000  to  50,000,000  streptococci, 
i  lancet,  1907,  ii.  36", 


STREPTOCOCCIC    VACCINES  363 

Waiters  and  Eaton  1  speak  highly  of  polyvalent 
vaccines.  Western 3  states  that  while  the  mortality  of 
all  cases  in  which  living  organisms  are  found  in  the 
blood  is  from  85  to  95  per  cent.,  after  the  use  of  vaccines 
it  is  reduced  to  55  per  cent. 

Barr  and  Douglas  3  record  the  apparent  cure  of  a  case  of 
ulcerative  endocarditis  by  means  of  a  vaccine  prepared 
from  the  actual  organism  derived  from  the  patient.  Horder  4 
also  tried  this  method,  but  without  success.  We  ourselves 
have  had  cases  in  which  the  cure  has  apparently  depended 
upon  the  vaccine  used ;  but  on  the  other  hand  we  have  had 
many  disappointing  cases  where  the  vaccine  has  failed  to 
avert  the  fatal  termination. 

Craig  5  states  that  he  has  collected  from  the  literature 
29  cases  of  acute  ulcerative  endocarditis  treated  with 
vaccines  :  of  these  13  were  cured  and  8  improved.  It  may 
be  well  to  repeat  here  that  unsuccessful  cases  are  not 
usually  recorded. 

In  localized  infections  with  streptococci  good  may  be 
effected.  Wynkoop  °  records  a  case  in  which  streptococci 
were  found  in  the  cerebro-spinal  fluid,  and  cure  resulted 
after  the  use  of  a  vaccine. 

Still7  records  10  cases  of  erysipelas  in  infants  treated 
with  vaccines,  with  1  death.  In  7  cases  a  streptococcic 
vaccine  alone  was  used ;  in  1  a  mixed  vaccine  of  strepto- 
cocci, staphylococci,  and  Bacillus  coli ;  and  in  2  a  "mixed 
phylacogen."  Weinstein8  cured  postoperative  fistulas  by 
the  use  of  vaccines. 

In  a  case  of  appendicitis  in  which  oedema  occurred 

1  Boston  Med.  and  Surg.  Journ.,  April  13,   1911. 
"  Lancet,  1912,  i.  351. 

3  Ibid.,  1907,  i.  499. 

4  Ibid.,  July  16,  1904. 

5  Med.  Record,  1911,  Ixxx.   1015. 

6  N.Y.  Med.  Jonrn.,  July  9,   1910. 

7  Med.  Record,  1913,  Ixxxiii.  573. 

8  Berlin,  Wn.  Woch,,  1906,  No.  39, 


364       SERUMS,    VACCINES,    AND    TOXINS 

after  operation  in  the  neighbourhood  of  the  wound, 
Hawkins  and  Corner *  successfully  employed  inoculations 
of  a  vaccine  of  Streptococcus  fcecalis,  the  organism  present. 
Inoculations  of  a  vaccine  of  B.  coli  were  employed  simul- 
taneously, but  Wright,  who  carried  out  the  opsonic  and 
bacteriological  investigations  in  the  case,  considered  that 
this  organism  played  at  most  a  subsidiary  part. 

General  Conclusions. — From  what  has  already  been 
said  regarding  the  various  species  of  streptococci,  it  would 
appear  probable  that  stock  vaccines  would  be  useless  in 
the  treatment  of  generalized  streptococcic  infections ;  and 
in  practice  this  is  found  to  be  so — the  vaccine  employed 
must  be  prepared  from  that  species  actually  infecting  the 
patient.  Further,  as  time  is  of  such  great  importance, 
every  device  that  will  shorten  the  period  spent  in  prepar- 
ing the  vaccine  must  be  adopted.  Consequently,  culti- 
vations from  septic  material  should  be  planted  directly 
on  to  blood-agar  plates,  and,  if  these  are  carefully  observed 
during  incubation,  the  vaccine  can  often  be  completed 
in  24  hours  when  the  streptococcus  is  present  in  pure 
culture ;  but  even  when  several  different  kinds  of  bacteria 
are  present  it  will  usually  be  found  possible  to  estab- 
lish pure  cultures  of  the  streptococcus  after  at  most  12 
hours;  and  cultivations  12  to  18  hours  old  will  suffice  to 
prepare  a  few  doses  of  vaccine,  so  that  treatment  can  often 
be  commenced  within  36  hours.  It  is  possible  to  adjust 
the  dosage  of  vaccine  without  estimating  the  movements  of 
the  opsonic  index,  and  in  the  absence  of  this  exact  guide  the 
temperature  and  pulse  must  be  carefully  watched,  for  it 
may  be  taken  as  a  general,  though  not  invariable,  rule  that 
high  temperature  and  rapid  feeble  pulse  coincide  with  a 
low  index.  The  object  to  be  aimed  at  is  the  elimination 
of  the  negative  phase  and  the  production  of  a  series  of  short 
positive  phases  gradually  increasing  in  duration.  Con- 
sequently, the  initial  dose  should  be  small— from  0-5 
*  Brit.  Med.  Joitrn.,  1908,  ii,  782, 


RHEUMATISM    AND    CHOREA  365 

to  2'5  millions.  With  such  a  dose  the  negative  phase  is 
short,  sometimes  absent ;  consequently  a  fall  in  temperature 
usually  occurs  in  about  12  hours.  But  the  succeeding 
positive  phase  is  also  short,  and  it  is  often  necessary  to 
repeat  the  dose  in  36  to  48  hours.  Subsequent  doses, 
gradually  increased  in  size,  are  generally  needed  at 
gradually  increasing  intervals,  until  convalescence  is 
established. 

2.  RHEUMATISM  AND   CHOREA 

Etiology. — The  causation  of  rheumatic  fever,  and  of 

the  chronic  affections  of  the  joints  generally  described  as 
rheumatic,  is  not  definitely  known. 

Many  observers  have  found  micro-organisms  in  the 
blood  and  synovial  fluid  of  patients  suffering  from  acute 
rheumatism.  A  large  number  of  different  bacteria  have 
been  described  in  this  connection — staphylococci,  strepto- 
cocci, diplococci,  and  bacilli.  For  practical  purposes  the 
question  of  the  microbial  origin  of  the  disease  is  at  present 
associated  with  the  claims  of  an  organism  first  discovered 
by  Apert  and  Triboulet  (1898),  and  subsequently  investi- 
gated by  Wassermann,  and  in  this  country  by  Poynton 
and  Paine. 

Walker  calls  the  organism  the  Micrococcus  rheumaticus. 
It  would  be  preferable,  perhaps,  to  call  it  a  streptococcus, 
as  it  appears  to  belong  to  this  group. 

With  regard  to  the  specific  nature  of  this  organism, 
no  certain  verdict  has  been  pronounced  as  yet.  The 
opinions  of  some  authorities  as  to  the  unity  of  the  strepto- 
cocci have  already  been  mentioned.  On  the  other  hand, 
it  is  difficult  to  believe  that  so  distinct  a  clinical  disease  as 
rheumatism  ca(n  be  due  to  the  same  cocci  which  produce 
suppuration.  If  the  rheumatic  cocci  be  merely  an  at- 
tenuated form  of  these,  it  is  curious  that  suppuration  is 
practically  never  seen  in  rheumatic  joints,  as  it  might  have 
been  expected  that  the  organisms  would  not  infrequently 
gain  increased  virulence  in  susceptible  persons.  There  is 


366       SERUMS,    VACCINES,    AND   TOXINS 

no  reason  to  believe  that  rheumatic  subjects  are  in  any  way 
refractory  to  suppurative  lesions.  Walker,  moreover,  finds 
that  the  rheumatic  cocci  will  grow  in  a  filtered  culture-fluid 
in  which  other  streptococci  have  been  grown  and  have 
died  out.  This,  which  has  been  alluded  to  as  Mannorek's 
test  for  the  unity  of  the  streptococci,  appears  to  show  that 
the  Streptococcus  rheumaticus  is  distinct  from  ordinary 
pyogenic  organisms,  whilst  many  observers  consider  that 
the  organism  isolated  from  the  joints  is  a  variety  of  the 
pneumococcus. 

It  must  be  mentioned  that  some  observers  have  failed 
altogether  to  find  micro-organisms  in  cases  of  acute  rheumat- 
ism. Thus,  McCrae  l  examined  270  cases  with  practically 
negative  results  ;  and  Triboulet,2  finding  organisms  in  some 
cases  and  not  in  others,  considers  that  the  sterile  cases 
represent  the  true  disease,  while  those  due  to  organisms 
only  simulate  rheumatism.  In  any  case  there  will  be  found 
but  few  bacteriologists  willing  to  accept  the  Streptococcus 
r/ieumaticus  as  a  specific  micro-organism,  or  as  the  specific 
cause  of  the  disease. 

Menzer's  serum. — The  serum  used  by  Menzer  is  pre- 
pared from  streptococci  derived  from  human  sources.  The 
effects  said  to  be  produced  in  cases  of  chronic  rheumatism 
are  very  remarkable,  as,  according  to  Menzer's  account,3 
the  injection  of  the  serum  gives  rise  to  a  reaction  of  an 
inflammatory  nature  at  the  seats  of  rheumatic  lesions  (the 
joints),  which  is  followed  by  improvement.  This  peculiar 
result  of  the  serum  would  suggest,  as  was  pointed  out  by 
Blumenthal,  that  the  serum  is  not  antitoxic  or  antibacterial, 
but  contains  a  toxin  similar  to  tuberculin  or  mallein.  The 
reaction  is  exactly  parallel  to  that  which  follows  an  in- 
jection of  the  old  tuberculin  in  a  patient  suffering  from 
a  tuberculous  joint.  Menzer,  however,  holds  that  his 
serum  is  antibacterial,  and  from  what  is  known  of  its  mode 

1  Journ.  of  the  American  Med.  Assoc.,  Jan.  3,  1903. 

1  Gaz.  des  H6p.,  April  4,  1903. 

8  Zeittehr.f.  klin.  Med.,  1902,  xlvii.  109. 


ANTIRHEUMATIC    SERUM  367 

of  preparation  it  should  be  of  this  nature.  He  suggests 
the  explanation  that  the  reaction  is  due  to  destruction  of 
the  cocci  present  in  the  patient  and  to  the  resulting  rapid 
absorption  of  intracellular  toxins.  Symptoms  of  constitu- 
tional disturbance  also  accompany  the  injections  of  serum 
in  rheumatic  patients,  viz.  rise  of  temperature,  headache, 
sore-throat,  and  enlargement  of  lymphatic  glands.  Car- 
diac disease,  if  present,  may  at  first  be  aggravated  by 
the  remedy,  but  is  subsequently  improved.  The  local 
inflammatory  symptoms  are  not  seen  in  cases  of  gonorrhceal 
rheumatism  which  are  treated  with  the  serum. 

Menzer  gives  in  his  original  paper  an  account  of  seven 
cases  of  rheumatism  treated  by  his  serum,  and  holds  that 
they  were  all  improved.  Relapse  did  not  follow  the  treat' 
ment.  In  one  case,  which  exhibited  symptoms  of  nephritis, 
these  were  at  first  aggravated  by  the  use  of  serum,  but 
finally  improvement  was  effected ;  indeed,  Menzer  suggests 
that  the  serum  may  prove  useful  in  the  treatment  of  some 
cases  of  chronic  renal  disease  in  which  a  local  stimulating 
effect  may  be  beneficial.  He  does  not  claim  that  an  actual 
cure  of  rheumatic  fever,  or  even  a  cutting-short  of  the 
disease,  is  directly  effected  by  the  serum,  but  thinks  that 
by  its  means  the  resistance  of  the  patient  is  raised.  This 
theory  would  be  consistent  with  an  action  analogous  to 
that  of  tuberculin  ;  which,  however,  Menzer  will  not  allow. 

A  patient  who  had  suffered  from  chronic  rheumatism, 
and  had  been  ineffectually  treated  by  ordinary  means,  was 
shown  by  Menzer  at  the  Berlin  Medical  Society.1  As  the 
result  of  serum  treatment  the  man  had  so  far  improved 
that  he  could  get  about  with  sticks  after  four  weeks' 
treatment. 

The  dose  of, the  serum  is  not  well  established.  Five  to 
10  c.c.  may  be  given  experimentally,  but  large  quantities 
may  be  used  if  no  ill  effects  are  observed.  Sinnhuber2 

1  Berlin.  Vereinf.  inn,  Med.,  March  23,  1903.    See   Centralbl.f. 
inn.  Med.,  1903,  p.  410. 

2  Quoted  by  Menzer,  Munch,  med.  Woch.,  1904,  p.  461. 


368       SERUMS,    VACCINES,    AND    TOXINS 

supports  Menzer  in  recommending  the  use  of  the  serum 
in  cases  which  have  become  chronic. 

Very  great  interest  attaches  to  Menzer's  experiments, 
but  at  present  no  definite  opinion  can  l>e  expressed  as  to 
the  merits  of  the  treatment.  Cases  of  acute  rheumatism 
generally  yield  readily  to  the  use  of  salicylates,  and  in  view 
of  this  fact  it  is  natural  to  hesitate  somewhat  before 
prescribing  a  remedy  which  seems  capable  of  giving  rise  to 
alarming  symptoms.  It  would  seem,  for  the  present  at 
least,  wise  to  refrain  from  using  the  new  remedy  in  cases 
complicated  by  recent  endocarditis  or  other  acute  lesions  of 
important  parts  (pleurisy,  pericarditis,  etc.).  In  chronic 
cases,  however,  it  might  be  safely  tried.  These  are  so 
rebellious  to  treatment  by  ordinary  means  that  any  method 
which  holds  out  a  prospect  of  success  is  to  be  welcomed. 
No  danger  seems  to  reside  in  the  use  of  the  serum  in  such 
instances,  while  it  is  easy  to  suppose  that  the  local  reaction 
might  have  a  curative  influence  by  its  stimulating  effect  on 
indolent  tissues. 

Chorea. — The  connection  between  this  disease  and 
rheumatism  is  not  exactly  ascertained.  Many  writeis 
consider  that  chorea  is  a  nervous  manifestation  of  the 
rheumatic  poison,  while  others  see  in  rheumatism  only 
one  of  several  debilitating  diseases  which  may  cause 
the  peculiar  condition  of  the  motor  centres  characteristic 
of  chorea.  Bacteriological  examination  has  in  some  in- 
stances shown  the  existence  in  chorea  of  organisms  similar 
to  those  which  have  been  found  in  acute  rheumatism, 
and  some  experimenters  (Poynton  and  Paine,  Walker) 
have  produced  in  animals,  by  injection  of  these  organisms, 
a  condition  which  they  consider  to  represent  the  chorea 
of  human  beings. 

Preobrajensky  l  treated  several  cases  of  severe  chorea, 
which  he  considered  to  be  of  an  infective  type,  with  a  poly- 
valent antistreptococcic  serum.  Great  improvement  ensued, 
Very  rapid  diminution  in  the  symptoms  being  observed. 
1  Quoted  in  La  Semaine  Med.,  1902,  p.  412. 


SCARLATINA  369 

Relapses  occurred  in  some  of  the  cases,  but  renewed  use  of 
the  serum  caused  their  disappearance. 

Chorea,  like  rheumatism,  is  a  disease  in  which  it  is  very 
difficult  to  make  sure  of  the  effects  attributable  to  drugs. 
Much  conflict  of  opinion  has,  for  instance,  been  exhibited 
as  to  the  efficacy  of  arsenic  in  this  ailment ;  and  other 
remedies  have  been  vaunted  as  specifics,  only  to  be  rejected 
in  the  light  of  further  observation.  Hence  the  claims  of 
antistreptococcic  serum  to  cut  short  the  disease  must  be 
closely  scrutinized  before  they  are  accepted. 

3.  SCARLATINA 

Etiology. — The  causation  of  scarlatina  or  scarlet  fever 
is  not  definitely  established.  Many  observers  have  described 
cocci  in  connection  with  this  disease,  and  there  is  a 
tendency  to  regard  these  as  the  exciting  cause  of  the  malady, 
but  so  far  exact  proof  is  wanting. 

Mallory  l  has  described  " protozoon-like  bodies"  in  the 
epithelial  cells  of  patients  who  had  died  of  scarlatina, 
and  is  inclined  to  consider  them  to  be  the  causal 
agents.  He  named  the  organism  (?)  provisionally  Cyclaster 
scarlatinalis. 

In  view  of  the  great  infectivity  of  scarlet  fever,  the 
contagion  being  conveyed  from  one  person  to  another 
without  direct  contact,  it  seems  improbable  that  the  Strepto- 
coccus pyogenes  can  be  the  cause  of  the  disease.  Conditions 
due  to  infection  with  virulent  forms  of  this  organism  seem 
to  be  propagated  only  by  direct  transference  (hands,  instru- 
ments, etc.),  and  it  is  unlikely  that  an  attenuated  germ, 
such  as  that  of  scarlatina  would  almost  undoubtedly  be, 
could  be  more  readily  communicated  than  the  virulent 
kind.  Provisionally,  we  may  conclude  that  the  disease  is 
due  to  some  organism  at  present  unidentified,  either 
owing  to  its  ultra-microscopical  size,  or  to  failure  to  cul- 
tivate it  outside  the  body.  The  constant  association 
of  streptococci  with  scarlatina  would  indicate  that  the 

1  Joiirn.  of  Med.  Research,  Jan.,  1904,  p.  483. 
Y 


370       SERUMS,    VACCINES,    AND    TOXINS 

diseased  tissues  afford  a  favourable  pabulum  for  these  cocci, 
which  take  advantage  of  the  opportunity  thus  offered,  and 
are  probably  responsible  for  many  of  the  complications 
of  the  malady,  such  as  ulceration  of  the  throat  and  disease 
of  the  middle  ear,  just  as  they  appear  to  excite  suppurative 
lesions  in  other  acute  diseases. 

SERUM  TREATMENT 

Moser,1  who  found  that  of  99  cases  of  scarlatina  73 
exhibited  cocci  in  their  blood,  prepared,  by  injecting  horses 
with  these  organisms,  a  specific  antiscarlatinal  serum.  This 
was  tried  by  Escherich,  apparently  with  good  results.  He 
records  that  the  mortality  was  reduced  by  its  means  to 
8'9  per  cent.,  whereas  in  other  hospitals  at  the  same  time, 
where  the  serum  was  not  used,  the  death-i-ate  amounted  to 
13'9  per  cent.  The  injection  of  the  serum  was  followed  by 
fall  of  temperature  and  general  improvement. 

Bokay,2  Zuppinger,3  and  Winocouroff l  confirm  these 
observations.  Mendelsohn,5  on  the  other  hand,  reports 
unfavourably,  finding  the  serum  quite  useless. 

Marpmann6  prepared  a  "specific"  serum  by  injecting 
animals  with  the  blood  of  scarlet-fever  patients,  with 
emulsion  of  their  epidermic  scales  collected  in  the  peeling 
stage,  and  with  their  urine.  He  prepares  a  stronger  serum 
for  treatment  and  a  weaker  for  prophylaxis.  Campe7  re- 
ports favourably  on  the  value  of  the  serum,  which  is 
called  "  scarlatin." 

AntistreptOCOCCic  serum. — Baginsky  8  tried  Marmo- 

1  Quoted  in  La  Seinaine  Med.,  1902,  Appendices,  p.  clviii. 

-  Jahrb.  f.  Kinderheilk.,jL\\.  -128. 

8   Wien.  kiln.  Woch.,  1905,  No.  44. 

4  Ibid.,  p.  695.  See  also  Egis  and  Langovoy,  Jahrb.  f.  Kinder- 
heilk.,  1907,  xvi.  514;  Eguez,  Komski  Vratcfi,  1904,  p.  1635;  Schick, 
Dent.  mcd.  Woch.,  1905,  p.  2092. 

6  Ibid.,  1905,  p.  461. 

6  Abstr.  in  CentralU.  f.  inn.  Ned.,  1905,  p.  999. 

7  Serlin.  klin.  Woch.,  1905,  No.  52. 

8  Ibid.,  1902,  p.  304. 


SERUM   TREATMENT  OF   SCARLATINA    371 

rek's  serum  in  cases  of  scarlatina,  but  found  that  it  did  not 
produce  any  good  effect  on  the  course  of  the  disease. 
Subsequently  he  made  use  of  a  serum  prepared  by  Aronson, 
with  better  results,  the  mortality  from  the  disease  falling 
from  14  to  11  per  cent.  The  figures  do  not  seem  very 
striking.  Cumston1  found  a  polyvalent  antistreptococcic 
serum  useful  in  " septic"  cases  of  scarlet  fever. 

In  view  of  the  suppurative  lesions  which  may  occur  as 
complications  of  scarlatina  (ulceration  of  the  throat,  otitis 
media,  ei.c.),  it  would  seem  advisable  to  use  an  antistrepto- 
coccic serum  in  severe  cases,  witli  a  view  to  prevent  or 
relieve  these  lesions.  It  can  hardly  be  expected  that  the 
course  of  the  disease  itself  will  be  modified  by  this  procedure, 
but  in  this  country  scarlet  fever  is  a  mild  disease,  and  it  is 
rather  the  complications  than  the  primary  infection  which 
are  to  be  feared.  In  the  anginose  form  the  use  of  the 
serum  would  seem  specially  indicated,  as  this  is  almost 
certainly  due  to  secondary  infection.  The  mortality  in 
these  cases  is  high,  and  even  in  those  which  recover  the 
convalescence  is  long  and  tedious.  Mackie 3  has  used 
antistreptococcic  serum  in  these  cases  with  good  results. 

Serum  of  convalescents.  —  Leyden3  has  observed 
the  effects  of  injecting  serum  derived  from  convalescents 
from  scarlet  fever  into  patients  suffering  from  the  dis- 
ease. He  thinks  that  good  results  ensue.  According  to 
his  observations,  the  disease  is  cut  short,  the  temperature 
reaching  normal  some  days  earlier  than  it  would  otherwise 
have  done.  No  critical  fall  of  the  fever  is,  however,  seen. 
The  doses  administered  were  from  10  to  20  c.c.,  and  no  ill 
effects  were  produced. 

These  experiments  are  of  theoretical  rather  than  practi- 
cal interest,  as  it,  is  not  to  be  expected  that  such  a  remedy 
could  become  generally  used.  Convalescents  from  a  disease 
could  not  be  expected  to  sacrifice  a  portion  of  their  blood 

1  Brit.  Med.  Journ.,  1908,  i.  1290. 

2  Lancet,  1904,  i.  493. 

3  Deut.  Arch.f.  klin.  Med.,  Bd.  Ixxiii. 


372       SERUMS,   VACCINES,    AND   TOXINS 

for  the  benefit  of  other  patients — at  all  events,  in  this 
country.  A  perusal  of  Leyden's  paper  does  not  convey  the 
impression  that  the  observed  results  \vere  at  all  strikingly 
encouraging. 

VACCINE  TREATMENT 

Gabritschewsky1  has  prepared  a  vaccine  consisting  of 
a  bouillon  culture  of  streptococci  isolated  from  cases  of 
scarlatina,  killed  by  heating  to  60°  C.,  and  preserved 
by  the  addition  of  0'5  per  ceiit.  of  phenol.  It  is  used  as 
a  prophylactic,  01  c.c.  being  given  for  each  year  of  the 
child's  age,  with  a  maximum  dose  of  1  c.c.  The  vaccine  has 
been  extensively  used  in  Russia,  where  severe  epidemics  of 
scarlet  fever  occur.  Statistics  seem  to  favour  its  employ- 
ment in  these  circumstances.  Thus  Nikitin  found  the 
incidence  of  the  disease  1 4  per  cent,  in  vaccinated  villages, 
16  per  cent,  in  those  un vaccinated  ;  and  other  observers 
give  similar  figures.2 

1  Bull.  Inst.  Pasteur,  v.  575  ;  Centi-albl.  f.  Jialtt.,  I.  Orig.,  1006, 
xli.  377,  719.  Cf.  Langovoy,  ibid.,  1906,  xlii.  (Orig.),  362,  463. 

-  See  R.  M.  Smith,  Huston  Mcd.  mul  >'«/•</.  Jnur/i.,  1910, 
clxii.  242. 


CHAPTER   XJX 

OTHER    INFECTIONS    DUE    TO    COCCI 
PNEUMOCOCCIC    INFECTIONS 

Causation. — The  organism  to  which  the  vast  majority 
of  all  cases  of  acute  pneumonia  are  due  is  the  Diplo- 
coccus  pneumonia,  or  pneumococcus  of  Frankel  and  Weich- 
selbaum. 

Another  organism  occasionally  associated  with  pneu- 
monia is  the  pneumobacillus  of  Friedlander  (1883).  This 
bacillus  may  also  give  rise  'to  a  form  of  membranous 
sore-throat,  and  has  been  found  in  abscesses  in  various 
parts  of  the  body,  as  well  as  in  pleurisy,  endocarditis, 
otitis,  rhinitis,  etc.  The  pneumobacillus  is  agglutinated 
by  the  serum  of  patients  infected  by  it,  and  exhibits 
chain-formation  if  grown  in  immune  serum.  A  special 
phenomenon,  "amorphous  agglutination,"  the  nature  of 
which  is  doubtful,  is  described  by  Schmidt.1 

Agglutination. — The  diplococci  are  agglutinated  by  the 
serum  of  immunized  animals  or  of  patients  suffering  from 
the  disease.  The  reaction  is  not  so  easily  demonstrated  as 
in  the  case  of  B.  typhosus,  Micrococcus  melitensis,  etc. ;  and 
it  does  not  appear  to  be  of  much  practical  value  for  clinical 
diagnosis.  The  phenomenon  can  be  best  shown  by  growing 
the  cocci  in  some  of  the  immune  serum,  a  control  growth 
being  made  in  normal  serum.  In  the  latter  the  organisms 
produce  a  turbidity  of  the  fluid,  and  under  the  micro- 
scope are  seen  to  be  uniformly  scattered  about  in  pairs 
or  short  chains.  In  agglutinative  serum  the  organisms 
grow  in  flocculi,  while  the  rest  of  the  fluid  remains  clear. 

v    *  Miinch.  med.  Woch.,  1903,  No.  30,  p.  873. 
373 


374       SERUMS,    VACCINES,    AND    TOXINS 

Microscopically  the  cocci  are  seen  to  be  adherent  in  long 
chains  or  in  clumps.1  Jehle,2  who  apparently  used  the  ordi- 
nary technique  for  agglutination  experiments,  reports  that 
in  children  the  reaction  appears  early  in  the  disease,  so  as 
to  be  of  diagnostic  value,  and  that  it  may  be  useful  for 
prognosis,  since  pure  pneumococcic  affections  generally 
tend  to  recovery. 

Complement  -  fixation.  —  Isabolinsky  and  Dichno,3 
using  an  antigen  consisting  of  an  extract  of  pueumonic 
lung,  found  a  positive  reaction  in  9  out  of  12  cases  of 
pneumonia.  Of  the  3  which  failed  to  give  the  reaction, 
1  patient  died  and  the  other  2  were  tested  in  a  very  early 
stage  of  the  disease.  Cases  of  pleurisy  and  influenzal 
pneumonia  gave  a  negative  reaction. 

Serum  treatment. — G.  and  F.  Klemperer  4  were  the 
first  to  attempt  to  treat  cases  of  pneumonia  by  means 
of  an  antagonistic  serum.  They  prepared  this  from 
rabbits  .immunized  by  injections  of  pneumococci,  using  a 
precipitate  from  the  blood  of  these  animals  which  they 
called  "  antipneumotoxin."  In  6  cases  so  treated  these 
authors  claimed  good  results.  "Wash  bourn  5  immunized  a 
pony,  and  Parr 6  an  ass ;  the  latter  treated  22  cases  with 
the  serum,  with  2  deaths,  both  in  patients  who  were 
moribund  at  the  time  of  admission  ;  he  found  that  doses 
of  50  c.c.  were  followed  by  crisis  and  recovery.  Biggs7 
immunized  a  horse,  and  found  that  the  serum  would  pro- 
tect rabbits  against  1,000  lethal  doses  of  the  cocci  ;  but  he 
obtained  only  indecisive  results  in  man. 

Pane  8  prepai-ed  a  serum   from  donkeys,  and  recorded 

1  See  Eyre  and  Washbourn,  Jouni.  of  Pathol.,  1898,  v.  13;  Besan^on 
and  Griffon,  Ann.  de  Vlnst.  Pasteur,  1900,  xiv.  449. 
•-   JTien.  klin.  Woch.,  Aug.  6,  1903,  No.  32,  p.  917. 
3  Abstr.  in  Zeitschr.  f.  Immnnttalnforsch.,  1912,  p.  217. 
*  Berl.  klin.   Jl'och.,  1891. 

5  Brit.  3fed.  Jouni..  1897,  i. 

6  Quoted  by  Biggs,  infra. 

7  Med.  Neics,  1899,  Ixxv.  97,  137. 

8  SifornM  Medicc,  1898. 


ANTIPNEUMOCOCCIC    SERUM  375 

very  favourable  results.  This  serum  was  capable  of  protect- 
ing laboratory  animals  against  3,000  lethal  doses.  Eyre  and 
Wash  bourn1  found  it  effective  against  four  out  of  five  strains 
of  pneumococci.  Maragliano,2  in  1898,  stated  that  "he  was 
more  and  more  convinced  of  the  antitoxic  (?)  power  of 
Pane's  serum,  and  of  its  efficacy  in  pneumonia."  Fanoni  3 
is  very  confident  of  the  value  of  this  preparation.  He  em- 
ploys doses  of  40  c.c.  daily,  and  finds  that  the  temperature 
is  lowered,  the  general  condition  of  the  patient  improved, 
and  resolution  of  the  affected  lung  accelerated.  In  children 
especially  good  results  are  to  be  obtained. 

More  recently  Oreste4  has  written  in  favour  of  Pane's 
serum  ;  but  Horder  and  Scofield 5  found  it  useless  in  a 
case  of  pneumococcic  endocarditis. 

Lambert  °  immunized  horses  and  treated  cases  with  the 
serum.  He  found  that  slight  reduction  of  the  temperature 
was  effected,  but  crisis  was  not  induced.  The  pneumococci 
may  disappear  from  the  blood,  if  they  are  present  there  ; 
in  other  words,  a  pneumococcic  septicaemia  may  be  pre- 
vented. The  total  effect  obtained  is,  however,  small ;  and 
Lambert  has  given  up  the  use  of  the  remedy. 

Reiner  prepared  a  serum  by  injecting  horses,  cattle,  and 
goats  with  different  strains  of  pneumococci  and  mixing  the 
serums  thence  obtained.  It  is  favourably  reported  on  by 
Knauth,7  Paessler,8  Tauber,9  and  others,  doses  of  10  to 
30  c.c.  being  given.  Dorendorf 10  states  that  Rb'mer's  serum 
is  useless  in  cases  of  pneumonia,  and  this  is  our  own 
experience. 

1  Brit.  Med.  Journ.,  1899,  ii.  586. 

"  Quoted  by  Fanoni,  Med.  Record,  March  10,  1900,  p.  431. 

3  Pediatrics,  May  15,  1900. 

4  Gaz.  degli,  Ospedali,  1906,  No.  22. 

5  Lancet,  1905,  i.  1333. 

6  Journ.  of  Amer.  Med.  Assae.,  1900,  i.  901. 

7  Dent.  med.  Woc\.,  1905,  No.  12. 

8  Deut.  Arch.  f.  klin.  Med.,  Hft.  3  and  4. 

9  Wien.  Uj,n.  Woch.,  1906,  Xo.  11. 
10  Med.  Klinik,  1912,  p.  1579. 


376       SERUMS,    VACCINES,    AND    TOXINS 

Neufeld  and  Haendel1  find  that  there  are  several 
strains  of  pneuiuococcus,  so  that  a  polyvalent  serum  is 
necessary.  They  prepared  one  which  was  curative  for 
guineapigs  infected  with  pneumococci.  For  use  on  man 
large  doses  must  be  given  intravenously.  Geronne2  reports 
favourably  on  the  remedy,  finding  that  it  brings  down  the 
patient's  temperature  and  induces  a  feeling  of  well-being. 
It  does  not,  however,  lead  to  disappearance  of  the  physical 
signs  of  disease  in  the  lungs  ;  indeed,  he  suggests  that 
it  may  even  delay  resolution — which  seems  a  doubtful 
recommendation. 

With  regard  to  the  properties  of  a  serum  prepared  by 
injections  of  Diplococcus  pneumonia:  into  animals,  it  would 
be  natural  to  expect  it  to  be  bactericidal,  not  antitoxic. 
On  the  other  hand,  it  is  found  that  the  cocci  will  grow 
in  the  serum  of  patients  suffering  from  the  disease,  and 
in  that  of  immunized  animals  (see  p.  373).  Bokenham 3 
states  that  the  serum  has  no  effect  on  the  cocci  by  itself  : 
if,  however,  it  is  brought  into  contact  with  the  organisms 
in  the  presence  of  leucocytes,  it  causes  these  cells  to 
destroy  the  germs  by  phagocytosis,  i.e.  it  has  an  opsonic 
influence. 

The  value  of  serum  in  cases  of  ulcus  serpens  cornea, 
which  is  often  due  to  a  pneumococcic  infection,  is  in 
dispute.*  Allen 5  isolated  a  special  coccus  from  cases  of 
ulcerative  keratitis  and  found  vaccine  treatment  with  it 
useful.  The  employment  of  a  pneumococcus  vaccine  was 
ineffective. 

Serum  of  Convalescents. — Weisbecker6  first  em- 
ployed this  method  of  treatment  in  a  series  of  21  cases, 

1  Arli.  a.il.  Ka'ix.-i-l.  Grxundlteit taint,  1910.  xxxiv.  166. 

2  Ibid.,  p.  1699. 

3  lint.  Mcd.  Joimi.,  1900,  ii.  1080. 

4  See  Romer,  abstr.  in  Biochem.  Centralbl.,  1903,  p.  66,  and  Gatti, 
abstr.  ibid.,  p.  158. 

5  "Opsonic  Method  of  Treatment,"  1908,  p.  224. 

6  Munch,  med.  Woch.,  1899. 


VACCINES    IN    PNEUMONIA  377 

but,  in  spite  of  some  subjective  improvement,  he  con- 
sidered that  the  results  were  inconclusive.  Marchoux l 
thought  that  he  observed  good  effects  with  this  method. 

Vaccine  treatment. — At  first  sight  vaccine  treat- 
ment seems  scarcely  indicated  in  acute  pneumonia,  in 
which  there  is  a  general  intoxication  and  probably  septi- 
Cfemia.  Nevertheless,  the  attempt  to  influence  the  disease 
by  this  means  has  been  made,  and  it  would  seem  that 
in  some  cases  of  lobar  pneumonia  the  crisis  is  accele- 
rated by  some  days  when  vaccine  is  employed.  Craig2 
records  6  cases  in  aged  persons,  who  usually  succumb 
to  the  disease,  in  all  of  which  recovery  took  place.  He 
used  doses  of  20-50  millions  of  pneumococci,  administer- 
ing a  stock  vaccine  first  until  an  autogenous  preparation 
could  be  made.  In  a  later  publication  he  insists  that  the 
vaccine  must  be  given  early,  and  records  47  cases  with  7 
deaths,  and  a  series  in  private  practice  of  '20  cases  with 
1  death. 

Cohendy  and  Bertram! 3  used  sensitized  vaccine,  made  of 
many  strains  mixed,  and  believed  that  (?)  of  7  cases  6 
were  benefited,  1  negative. 

Shennan4says  that  he  used  vaccines  in  29  cases,  and 
has  no  doubt  of  their  value;  he  gave  doses  of  30-40 
millions.  Lyons  5  reports  4  cases  in  which  there  was  gene- 
ral improvement ;  the  disease  declined  by  lysis  instead  of 
by  crisis.  Raw,6  having  used  vaccines  in  207  cases,  finds 
it  difficult  to  estimate  their  value.  In  many  cases  there 
was  improvement  in  the  general  condition,  but  there  was 
no  acceleration  of  crisis,  and  some  cases  were  quite 
uninfluenced.  He  began  with  doses  of  50  millions,  in- 
creased to  100  millions  or  even  150  millions. 

1  Ann.  de  VInst.  Pasteur,   1899,  xiii.  193. 

*  Med.  Record,  1910,  Ixxvii.  259. 

3  Compt.  Rend.  Soc.  BioL,  1913,  Ixxiv.  532. 

4  Med.  Record,  1912,  Ixxxi.  427. 

*  Brit.  Med.  Journ.,  1913,  i.  992. 
6  Lancet.  1912.  i.  646. 


378       SERUMS,   VACCINES,    AND    TOXINS 

Wynn1  advocates  early  administration  and  large  (!) 
doses,  25-50  millions.  Wright,  Morgan,  Colebrook  and 
Dodgson2find  small  doses  in  treatment  of  no  value  (159 
cases) ;  a  single  large  dose  during  the  incubation  period 
may  diminish  the  severity  of  a  subsequent  attack.  Pro- 
phylactic injections  were  of  use  in  reducing  both  morbidity 
and  fatality  among  a  susceptible  population  (negroes). 
Raw3  collected  statistics  of  207  cases,  of  which  173  re- 
covered ;  Leary,4  83  cases,  with  71  recoveries.  Whorlow5 
mentions  a  case  of  chronic  pneumonia  (due  to  pneumo- 
cocci),  in  which  16  doses  of  vaccine  (2^-300  millions)  were 
given,  with  great  improvement.  Pio  and  Durand  6  refer  to 
a  case  with  abscess  of  the  lung  and  empyema,  attributable 
to  the  pneumo-bacillus,  much  benefited  by  a  corresponding 
vaccine. 

Vaccine  treatment  also  proves  useful  in  cases  of  local- 
ized infection  by  the  pneumococcus.  Thus  Magruder  and 
Webb  ~  gave  injections  of  14  and  20  millions  of  pneumo- 
cocci  in  a  case  of  pueumococcic  otitis  media,  with  benefit ; 
and  Lyon  8  successfully  treated  a  case  of  empyema  which 
did  not  heal  up  after  evacuation  of  the  pus,  by  inoculation 
of  the  organisms  (100  and  200  millions). 

Robinson 9  gave  injections  of  from  11  to  23  millions 
in  a  case  of  pneumococcic  j)eritonitis  with  good  effect ; 
and  Eyre  10  records  cases  of  pneumococcic  pycKmia  and  of 
peritonitis,  due  to  the  pneumococcus,  successfully  treated 
by  autogenous  pneumococcic  vaccines,  and  is  convinced  of 
the  value  of  vaccine  treatment  in  pneumococcic  infections. 

1  Lancet,  1914,  i.  354. 

2  Ibid..  1914.  i.  87. 

»  Ibid.,  1912,  i.  646. 

*  Botton  Med.  and  Surg.  Joiirn..  1909,  cxvi.  71 4. 

5  Lancet,  1913,  ii.  811. 

6  Lyon  Medical,  1914,  cxii.  775. 

7  Laryngoscope,  Nov.,  1907. 

8  Lancet,  1905,  i.  17 IS. 

9  Brit.  Mtd.  Journ.,  1909,  i.  651. 

40  Erasmus  Wilson  Lectures,  Lancet,  1908,  i.  539. 


DIPHTHERIAL  ANTITOXIN  IN  PNEUMONIA  379 

Chappie1  found  vaccine  in  doses  of  5  millions  useful 
in  cases  of  mdvo-vaginitis  in  children,  due  to  the  pneumo- 
coccus,  which  is  almost  as  common  a  cause  of  this  disease 
as  the  gonococcus. 

The  present  writers  recommend  quite  small  doses, 
viz.  5,  10,  and  25  millions,  the  vaccine  being  invariably 
prepared  from  the  organism  isolated  from  the  patient.  The 
effect  of  such  a  vaccine  upon  the  temperature  and  general 
condition  of  cases  of  empyema  doing  badly  after  opera- 
tion is  often  particularly  striking.  Broncho-pneumonia  due 
to  the  pneumococcus  is  also  amenable  to  treatment  with 
pneuniococcus  vaccine,  especially  chronic  cases  in  children. 

Diphtherial  antitoxin. — Talamon3  has  treated  50 
cases  of  pneumonia  with  antitoxin,  many  of  them  being 
alcoholic  patients,  and  some  of  them  old  persons.  The 
death-rate  was  14  per  cent.,  whereas  previously,  in  cases 
treated  symptomatically,  it  had  been  37  per  cent.  _He 
finds  that  if  the  serum  is  administered  before  the  fifth 
day  of  the  disease,  the  mortality  is  only  4  per  cent.  ; 
whereas,  if  it  is  not  given  till  after  the  sixth  day, 
the  death-rate  rises  to  24  per  cent.  He  gives  doses  of 
20  c.c.,  repeated  if  necessary  ;  in  grave  cases  he  injects 
20  c.c.  at  once,  and  repeats  the  dose  on  the  following 
morning  and  evening.  Bessoni 3  also  recommends  this 
treatment,  reporting  21  cases  in  which  it  was  used,  with 
a  mortality  of  4  per  cent.  ;  among  79  other  patients  not 
so  treated,  the  mortality  was  over  1C  per  cent.  Legros,4 
who  made  use  of  antitoxin  in  some  cases  of  pneumonia, 
failed  to  obtain  any  benefit.  The  same  criticism  probably 
applies  to  the  use  of  diphtherial  antitoxin  in  pneumonia 
as  in  septic  conditions  (see  p.  359). 

O'Malley 5  believes  that  antitoxin  is  a  very  valuable 

1  Lancet,  1912,  i.  1685. 

2  La  Semaine  M6d.,  1901,  p.  69. 

8  Ann.  de  Mod.  et  Chir.  Infantile*,  Feb.  15,  1899. 

4  La  Semaine  Med.,  1901,  p.  158. 

5  A mer.  Med.,  Jan.  17,  1903. 


380       SERUMS,    VACCINES,    AND    TOXINS 

therapeutic  agent  in  cases  of  broncho-p  leumonia  in  children, 
especially  in  the  forms  which  complicate  other  infective 
diseases  (measles,  influenza,  etc.). 

Chemotherapy. — Morgenroth1  endeavoured  to  apply 
Ehrlich's  ideal  therapia  magna  sterilisans,  by  the  use  of 
a  parasiticide  without  action  on  the  cells  of  the  host,  to 
infection  with  the  pneumococcus,  and  carried  out  researches 
on  the  efficacy  of  the  substance  known  as  jethyl-hydro- 
cuprein  hydrochlorate  ("optochiu  ")  as  a  remedy  for  such 
condition.  In  mice  this  drug  has  a  curative  effect  in  the 
presence  of  a  pneumococcal  septicaemia,  and  experiments 
by  Wright2  show  that  when  mixed  with  human  serum  it 
kills  pneumococci.  In  human  patients  suffering  from  pneu- 
monia it  does  not  seem,  according  to  this  last  observer,  to 
be  of  much  value,  while  it  is  possibly  capable  of  inducing 
blindness  owing  to  its  action  on  the  optic  tract.  The 
clinical  failure  of  the  drug  may  be  due  to  its  inability  to 
reach  the  cocci  in  the  consolidated  lung-tisssue  and  exudate. 
Other  observers,  however  ( V  etlesen,3  Lenne,1  v.  Baermann :>), 
believe  that  it  may  prove  a  useful  remedy ;  they  did  not 
experience  any  cases  of  permanent  ocular  injury. 

Summary. — The  results  obtained  up  to  the  present 
with  antipneumococcic  serum  are  disappointing.  It  is  cer- 
tain that  good  effects  are  produced  in  animals,  but  these  are 
in  the  direction  rather  of  prophylaxis  than  of  cure.  In  man, 
by  the  time  that  symptoms  of  pneumonia  have  developed, 
the  cocci  have  gained  so  firm  a  footing  and  have  increased 
to  such  numbers  that  only  a  very  potent  serum  of  a  bac- 
tericidal nature  could  be  expected  to  act  efficiently.  Those 
which  are  at  present  obtainable  do  not  seem  to  come  up 
to  this  standard.  It  is  also  possible  that  the  immune 
bodies  formed  in  the  lower  animals  do  not  find  suitable 

1  Morgenroth  and  Levy,  Jii-rL  11  in.  Wucli.,  1011,  Nos.  34,  44. 

2  "Drugs  and  Vaccines  in  Pneumonia."     London.  1014. 
8  Berl.  kiln.  Woch.,  1913,  No.  32. 

4  Ibid.,  No.  43. 

5  Zeitschr.  f.  exper.  Fathol.  u.  Therap.,  1914. 


STAPHYLOCOCCIC    AFFECTIONS          381 

complements  in  man.  Further,  it  appears  that  there  are 
different  strains  of  the  pneumococcus  which  react  dif- 
ferently to  antibodies.  More  might  be  expected  from  an 
antitoxic  than  from  a  germicidal  serum,  as  pneumonia  is 
characterized  by  symptoms  of  profound  intoxication ;  but 
as  it  has  not  been  possible  to  obtain  potent  solutions  of 
the  toxins  of  the  Diplococcus  pneumonic?,  no  such  serum  is 
at  present  available,  nor  is  there  any  immediate  prospect 
of  its  preparation.  Vaccine  treatment  of  acute  lobar 
pneumonia  must  still  be  regarded  as  in  the  experimental 
stage,  but  it  already  gives  promise  of  future  success  ;  whilst 
vaccines  in  the  treatment  of  chronic  pneumonic  affections 
are  of  considerable  value.  Chemotherapy  of  pneumonia  is 
not  at  present  to  be  very  seriously  regarded. 

STAPHYLOCOCCIC    AFFECTIONS 

Staphylococci  are  probably  always  present  on  the  skin 
of  mankind.  They  are  capable  of  giving  rise  to  suppura- 
tion in  favourable  circumstances.  Several  varieties  are 
generally  described,  Staphylococcus  pyogenes  aureus,  citreus, 
and  albus  being  the  commonest.  A  general  septicaemia  due 
to  any  variety  of  staphylococcus  may  be  produced  in  rare 
cases. 

Toxins  Of  StaphyloCOCCi.  —  Denys  found  that  by 
growing  the  staphylococci  in  fluid  derived  from  serous 
exudates  he  could  obtain  a  toxic  substance  which  had  the 
property  of  dissolving  the  leucocytes  of  the  blood.  The 
leucocytes,  when  treated  with  this  substance,  to  which  he 
gave  the  name  of  "  leucocidin,"  first  became  transparent, 
with  clearly  defined  nuclei,  and  finally  were  broken  up  and 
destroyed.  The  importance  of  this  toxin  in  the  parasitic  life 
of  the  bacteria  is  evident,  since  it  is  largely  by  means  of  the 
leucocytes  that  the  infected  individual  resists  the  invading 
organisms.  It  is  in  this  sense  that  we  must  look  upon  the 
formation  of  local  collections  of  leucocytes  (abscesses)  at 
the  points  where  the  cocci  settle.  Leucocidin  prepared  from 


382       SERUMS,   VACCINES,    AND   TOXINS 

cultures  in  rabbits  does  not  appear  to  have  the  power  of 
dissolving  human  leucocytes.  Other  poisonous  substances 
which  have  the  property  of  exciting  suppuration  have  been 
obtained  from  the  bodies  of  staphylococci.  To  one  of  these 
Leber  gave  the  name  of  "  phlogosin. '' 

Serum  treatment. — Several  attempts  have  been  made 
to  obtain  an  antistaphylococcic  serum.  Antibodies  can  be 
obtained  to  the  various  poisons  formed  by  the  cocci,  and 
rabbits  can  be  immunized  against  the  organisms.  A  serum 
capable  of  protecting  these  animals  against  several  times 
the  minimal  lethal  dose  of  the  cocci  has  been  prepared. 
It  is  doubtful  if  any  good  effects  are  to  be  looked  for  in 
man.  The  fact  that  the  leucocidin  which  is  active  for 
rabbits'  cells  does  not  affect  human  leucocytes  suggests  that 
both  the  toxins  and  their  antibodies  may  be  different  in 
different  surroundings,  so  that  animals'  serum  would  be 
unlikely  to  have  a  curative  action  in  human  disease. 
Vicquerart  and  Doyen  have  prepared  antistaphylococcic 
serums  for  purposes  of  treatment,  but  their  value  is  doubtful. 
Moritz  l  tried  antistaphylococcic  serum  in  six  cases  of  acute 
endocarditis  (5  c.c.  doses),  and  was  favourably  impressed  by 
the  apparent  results. 

Recently,  Thomas2  prepared  a  polyvalent  antistaphy- 
lococcic serum  by  injecting  a  ram  with  a  mixture  of 
cultures,  using  first  killed  and  finally  living  organisms. 
He  gave  doses  of  15  minims  (in  infants)  up  to  4  c.c.,  and 
noted  good  results  in  cases  of  boils  and  carbuncles. 

Agglutination. —  Staphylococci  are  agglutinated  by 
immune  serum,  and  this  reaction  is  suggested  by  Bruck, 
Michaelis  and  Schultze  3  as  a  means  of  diagnosis. 

Vaccination. — Wright 4  inaugurated  the  use  of  dead 
cultures  of  the  organisms  as  a  vaccine  in  cases  of  acne 
and  sycosis,  with  benefit. 

1  St.  Petertb.  med.  Woch.,  1898,  No.  19. 

*  Journ.  Amer.  Med.  Assoc.,  1913,  Ix.  1070. 

J  Zeitschr.f.  Hyg.,  1905, 1.  144. 

«  Lancet,  1902,  i.  874  ;  Brit.  Med.  Journ.,  1904,  i.  1075. 


&TAPHYLOCOCCIC    VACCINES  383 

Stock  vaccines  are  exceedingly  useful  in  staphylococcic 
infections,  though  distinctly  inferior  in  efficiency  to  auto- 
genous vaccines.  Least  useful  of  all  are  "  mixed  "  vaccines 
of  Staphylococcus  albus  and  aureus.  In  every  case  the  par- 
ticular type  of  staphylococcus  responsible  for  the  lesion, 
whether  aureus  or  albus,  must  be  determined,  and  a  cor- 
responding vaccine  be  employed.  Furunculosis,  solitary 
boils  and  carbuncles,  sycosis,  periostitis  and  osteomyelitis, 
staphylococcic  septicaemia  and  pyaemia  are  usually  due  to 
Staphylococcus  aureus ;  acne  indurata  to  Staphylococcus 
albus.  Generally  speaking,  the  control  afforded  by  the 
opsonic  index  can  be  dispensed  with,  and  the  injections 
given  in  accordance  with  the  clinical  phenomena.  For 
example,  in  a  case  of  furunculosis  the  immediate  result 
of  an  injection  of  vaccine  is  the  appearance  of  a  fresh  crop 
of  boils  ;  the  majority  of  these,  however,  quickly  abort, 
and  the  condition  improves.  The  appearance  of  another 
set  of  boils  is  the  signal  for  a  further  injection  of  vaccine. 
The  size  of  the  dose  is  a  matter  for  careful  consideration, 
and  can  usually  be  gauged  from  clinical  observations 
following  the  initial  tentative  dose.  In  treating  boils, 
etc.,  if  the  infecting  organism  is  diagnosed  in  the  early 
stages,  a  dose  of  10,  '25  or  50  millions  may  cause  rapid 
resolution.  If,  on  the  other  hand,  a  chronic  indurated 
focus  of  long  duration  is  present,  it  is  often  advisable  to 
administer  a 'large  dose  of  250  or  500  millions,  in  order 
temporarily  to  depress  the  patient's  resistance,  and  at  the 
same  time  to  hasten  the  breaking-down  of  the  abscess  by 
fomentations,  etc.,  as  a  preliminary  to  evacuating  the  pus. 

An  average  initial  dose  would  be  50  millions  in  a  local- 
ized suppuration,  and  a  dose  one-fifth  of  that  in  a  general- 
ized infection.  When  stock  vaccines  are  employed,  doses 
from  twice  to  four  times  as  large  should  be  administered  to 
ensure  comparable  results. 

And  here  we  would  again  insist  on  the  principle  that 
general  and  local  treatment  should  be  energetically  carried 
out  during  the  course  of  vaccine-therapy. 


384       SERUMS,   VACCINES,   AND   TOXINS 

In  some  chronic  conditions,  e.g.  furunculosis,  which 
improve  to  a  certain  point  and  then  appear  to  become 
stationary,  it  may  be  desirable  to  discontinue  the  vaccines 
for  a  time  and  then  resume  their  use.  On  the  other  hand, 
it  is  in  these  cases  that  sensitized  autogenous  vaccines,  at 
first  of  dead  cocci  and  afterwards  of  living  organisms,  find 
their  most  strikingly  successful  application. 

Gilchrist1  has  cured  bullous  erythema  with  vaccine. 
He  states  that  affections  due  to  Staphylococcus  aureus  may 
be  cured  by  the  use  of  an  inoculation  of  Stapltylococcus 
albus. 

PYORRHCEA.  ALVEOLARIS 

Pyorrhoea  alveolaris,  or  suppurative  periodontitis(Rigg's 
disease),  an  acute  or  chronic  inflammation  of  the  gum- 
margins  and  periodontal  membrane,  often  associated  with 
arthritis  and  other  distant  lesions,  and  sometimes  forming 
the  starting-point  for  a  general  septicaemia,  may  apparently 
be  the  result  of  the  pyogenic  activities  of  any  of  the 
pathogenic  bacteria,  and,  like  suppurative  processes  else- 
where, can  be  influenced  by  means  of  autogenous  vaccines. 
In  this  disease  particular  care  must  be  exercised  in 
determining  the  responsible  micro-organism — at  times  by 
no  means  an  easy  matter  —  and  frequently  the  infection 
is  a  mixed  one.  Streptococcus  pyogenes,  pneumococcas, 
Micrococcus  catarrhalis,  M.  tetragenus,  M.  paratetragenus, 
Staphylococcus  aureus,  B.  pneumonia,  and  ft.  coli  are 
among  those  most  commonly  found  singly  or  in  combina- 
tion. Small  doses,  5  or  10  millions,  of  the  appropriate 
vaccine,  injected  every  six  to  eight  days,  and  gradually 
increased  to  50  or  100  millions,  give  the  best  results. 
Treatment  may  need  to  be  prolonged  for  three  or  even  for 
six  months,  and  should  be  associated  throughout  with 
careful  local  treatment  by  the  dental  surgeon. 

Goadby  2  used  a  vaccine  of  Staphylococcus  aureus  suc- 

«•  Lancel,  1908,  ii.  471. 

2  Brit.  MeiL  Joiirn.,  1D08,  ii.  477. 


CEREBRO-SPINAL    MENINGITIS  385 

cessfully  in  2  cases  due  to  this  organism ;  more  recently l 
he  recorded  the  presence  of  a  streptococcus,  which  he 
appeared  to  regard  as  a  streptobacillus,  in  the  large  majority 
of  his  cases  in  which  arthritis  was  an  associated  symptom  ; 
and  summarized  the  results  from  treatment  with  autogenous 
vaccine  in  45  cases  as  23  cured,  14  relieved,  4  failures,  and 
the  remainder  under  treatment. 

Eyre  and  Payne2  recorded  33  cases  treated  with  auto- 
genous vaccines  (amongst  these  "  rheumatism  "  was  the  out- 
standing clinical  symptom  in  18),  of  whom  20  were  considered 
cured  and  5  improved.  The  responsible  organisms  in  these 
cases  were  Streptococcus  longus  (6),  M.  catarrhalis  (6),  a 
mixture  of  these  two  cocci  (8),  pneumococcus  (3),  and 
Staphylococcus  aureus  (2). 

Medalia3  finds  vaccines  specially  useful  in  cases  asso- 
ciated with  staphylococci  or  pneumococci. 

EPIDEMIC   CEREBRO-SPINAL   MENINGITIS 

Epidemic  cerebro-spinal  meningitis  is  characterized  by 
a  suppurative  or  fibrino-purulent  leptomeningitis  due  to  the 
Meningococcus  or  Diplococcus  intracdlularis  meningitidis, 
discovered  by  Weichselbaum.  The  disease  is  very  fatal 
apart  from  serum  treatment,  the  mortality  in  New  York 
being  over  75  per  cent.4  (1906-8).  Little  is  known  of  the 
toxins  of  this  organism,  which  have  not  been  obtained  in 
culture-media. 

Diagnosis. — The  agglutination  reaction  occurs  in  most 
cases  of  cerebro-spinal  meningitis,  and  may  be  used  as  a 
test  for  diagnostic  purposes.  It  may,  however,  be  absent 
during  the  first  few  days  of  the  disease.5  Young  cul- 
tivations of  a  strain  of  meningococcus  that  has  been 

1  Lancet,  1911,  i.  639. 

2  Proc.  Roy.  Soc.  Med.,  Dec..  1909. 

3  Boston  Med.  and  Surg.  Journ.,  Jan.,  1910. 

4  Fischer,  N.Y.  Med.  Journ.,  Dec.,  1909. 

5  Houston  and  Rankin,  Lancet,  1907,  i.  1213;  1908,  ii.  474. 
z 


386       SERUMS,    VACCINES,    AND   TOXINS 

frequently  subcultivated  in  the  laboratory  should  be  used 
for  this  reaction. 

Complement-fixation  tests  and  the  estimation  of  the 
opsonic  index  have  all  in  turn  been  advocated  in  the 
diagnosis  of  this  condition,  but  all  alike  sink  into  insig- 
nificance beside  the  demonstration  of  the  infective  micro- 
organism in  the  cerebro  spinal  fluid  removed  by  lumbar 
puncture,  more  especially  as  the  removal  of  the  fluid  forms 
such  an  important  therapeutic  measure  in  the  treatment 
of  the  infection. 

Serum  treatment. — Serum  for  therapeutic  purposes 
has  been  prepared  by  injecting  animals  with  the  cocci 
themselves,  and  is  presumably  bactericidal,  not  antitoxic. 

Jochmann1  obtained  from  horses,  goats,  and  sheep  a 
serum  which  agglutinated  the  cocci  in  dilutions  of  1  :  300  to 
1  :  15,000.  He  employed  it  on  human  patients,  both  sub- 
cutaneously  and  intrathecally,  with  good  effects.  Raczynski,- 
however,  failed  to  observe  any  benefit  from  the  use  of  this 
serum. 

Flexner  and  Jobling  3  also  prepared  a  serum  which  was 
used  in  421  cases  with  a  mortality  of  33  per  cent.,  or, 
excluding  moribund  cases,  of  25  per  cent.  Robb  *  treated 
90  cases  with  the  serum,  with  a  mortality  of  30  per  cent. 

A  serum  prepared  by  Kolle  and  Wassermann  has 
been  used  in  Germany,  Switzerland,  and  Italy.  Tobben  5 
found  that  the  mortality  in  his  cases  fell  from  56 -7  per 
cent,  to  34 '5  per  cent.  ;  and  Krohne  6  similarly  reduced 
the  mortality  from  GO  to  47 '6  per  cent.,  the  mortality  in 
cases  treated  within  the  first  two  days  being  33  per  cent. 
Currie  and  MacGregor  ~  treated  105  cases  with  serum, 

1  Deut.  med.  Woch.,  1906,  No.  20. 

2  Wien.  klin.  Woch.,  1907,  No.  52. 

3  Studies  from  Rockefeller  Inst.,  Reprints,  1909. 

4  Lancet,  1907.  i.  1213. 

6  Munch  med.  Woch.,  1907,  p.  2420. 

8  Zeitschr.f.  Medizinalbeamte,  1908,  No.  78. 

7  Lancet,  1908.  ii.  1072. 


CEREBRO-SPINAL    MENINGITIS  387 

using  several  different  brands,  with  a  mortality  of  64-8  per 
cent.,  as  compared  with  a  mortality  of  79-5  among  225 
cases  not  so  treated :  the  difference  is  not  very  striking. 
They  collected  from  other  sources  the  following  statistical 
results  in  addition  to  those  already  mentioned  :  Wasser- 
mann,  57  cases,  deaths  47-3  per  cent.;  Jochmann,  17  cases, 
deaths  29  per  cent. ;  Robb  (1908),  30  cases,  deaths  26'6  per 
cent. ;  Dunn,  15  cases,  deaths  20  per  cent.;  and  Levy,  40 
cases,  deaths  11-76  per  cent.  The  chief  inference  from 
the  figures  would  appear  to  be  that  the  disease  varies  much 
in  severity  at  different  times  and  in  different  places. 
Ker  l  treated  33  cases  with  Flexner  and  Jobling's  serum, 
with  a  mortality  of  40  per  cent.,  and  believes  that  the 
remedy  shortens  convalescence.  Dopter2  records  a  total 
of  402  cases  treated,  with  a  mortality  of  16-44  per  cent., 
as  against  a  mortality  of  65  per  cent,  in  the  untreated. 
The  doses  used  were  20-40  c.c.  for  adults  and  10-20  c.c. 
for  children,  administered  intrathecally. 

During  the  end  of  1914  and  the  early  months  of  1915 
numerous  cases  of  cerebro  -  spinal  meningitis  occurred 
amongst  adults  (chiefly  in  soldiers  aggregated  in  training 
camps),  the  majority  of  whom  were  treated  by  the  mili- 
tary surgeons  with  serum.  The  actual  results  are  not  yet 
available,  but  from  personal  communications  as  well  as 
our  own  experience  it  would  appear  that  polyvalent 
serums  are  essential  and  that  the  remedy  must  be  injected 
intrathecally  ;  given  subcutaneously,  serum  is  useless. 

Mackenzie  and  Martin  3  used  the  serum  of  convalescents, 
with  a  mortality  of  37*5  per  cent.;  and  diphtherial  antitoxic 
serum  was  tried  by  Huber,4  Waitzfelder/'  and  Balduzzi,6 
with  apparent  benefit. 

1  Edin.  Med.  Journ.,  Oct.,  1908,  p.  306. 

2  Ann.  de  Vln&t.  Pasteur,  1910,  xxiv.  96 

3  Lancet,  1908,  ii.  477. 

4  New  York  Med.  News,  April  16,  1905 

5  Med.  Record,  March  11,  1905. 

6  Gaz.  degli  Ospedali,  1907,  No,  36, 


388       SERUMS,   VACCINES,    AND   TOXINS 

Elder  and  levers1  used  injections  of  Rienzi's  anti- 
piieumococcic  serum  in  cases  of  cerebro-spinal  meningitis, 
on  the  ground  of  the  relationship  between  the  organism 
to  which  this  affection  is  due  and  the  pneumococcus,  and 
thought  that  some  improvement  was  produced.  Cases  of 
cerebro-spinal  meningitis  due  to  the  pneumococcus  or 
streptococci  should  be  treated  with  the  respective  serums 
injected  intrathecally  in  a  similar  manner,  but  in  those 
due  to  the  pneumococcus  the  prognosis  is  particularly 
grave. 

Method  of  injection. — The  serum  must  be  injected 
intrathecally  in  amounts  slightly  less  than  those  of  the 
cerebro-spinal  fluid  withdrawn  by  lumbar  puncture,  prob- 
ably 20-25  c.c.  or  30  c.c.  for  adults  and  from  5  c.c.  to 
10  c.c.  for  infants.  Sophian2  strongly  recommends  the 
injection  of  the  serum  by  gravity,  regulating  the  amount 
of  fluid  withdrawn  and  the  amount  of  serum  subsequently 
injected  by  the  movements  of  the  blood-pressure.  The 
withdrawal  of  fluid  and  the  injection  of  serum  must  be 
repeated  at  intervals  of  twenty-four  hours  until  the 
meningococci  are  found  to  have  disappeared  from  the  fluid 
withdrawn  from  the  spinal  canal. 

Vaccine  treatment. — Hector  Mackenzie3  treated  a 
case  with  injections  of  a  vaccine  consisting  of  dead 
meningococci.  The  first  dose  consisted  of  120,000,000 
cocci,  followed  ten  days  later  by  20,000,000,  and  again  a 
week  later  by  143,000,000.  A  final  injection  of  71,000,000 
organisms  was  given  a  week  later.  The  vaccine  was  pre- 
pared from  organisms  grown  from  the  patient's  cerebro- 
spinal  fluid  obtained  by  lumbar  puncture.  The  patient 
recovered.  Rendle  and  Mottram 4  also  made  use  of  a 
vaccine  of  dead  meningococci  in  doses  of  200,000  and 
500,000  organisms,  and  claim  that  benefit  resulted  from 

1  Scottish  Ned.  and  Surg.  Jonrn.,  1907,  xx.  215. 

2  Journ.  Amer.  Mel.  Assoc.,  1912,  p.  843. 

3  Brit.  Med.  Journ.,  1907,  i.  H08. 
*  Lancet,  1907,  ii.  220. 


GONORRHOEA  389 

the  treatment.  We  have  treated  three  cases  with  vaccine 
but  without  averting  the  ultimate  fatal  issue. 

The  opsonic  index  of  the  blood  is  usually  low  (04)  in 
cases  of  cerebro-spinal  meningitis,  and  may  be  raised  by 
injections  of  suitable  vaccine,  but,  owing  to  the  localization 
of  the  meningococci,  vaccine  treatment  is  not  to  be  preferred 
to  serum  therapeutics.  Probably  the  best  results  will  be 
obtained  by  the  combined  use  of  antiserum  and  autogenous 
vaccine.  The  estimation  of  the  opsonic  index  is  occasionally 
of  value  as  an  aid  to  diagnosis. 

Black !  has  carried  out  prophylactic  vaccination  against 
this  disease,  but  no  statistics  are  available  as  to  its  efficacy. 
He  finds  a  positive  complement-fixation  reaction  in  the 
serum  after  such  vaccination. 

GONORRHOEA 

Diplococcus  gonorrhcece,  or  the  gonococcus,  was  first 
described  by  Neisser  in  1879.  It  usually  gives  rise  to  a 
local  suppurative  affection  (urethritis,  conjunctivitis),  but 
it  may  cause  a  general  infection,  the  organisms  entering 
the  circulation  and  inducing  arthritis,  endocarditis,  and 
septicaemia. 

Toxins  and  antitoxins. — Christmas  2  grew  the  cocci 
artificially  and  obtained  a  poisonous  fluid.  A  toxic  solid, 
gonotoxin,  can  be  precipitated  from  this  by  ammonium 
sulphate;  it  is  not  dialysable,  and  is  not  destroyed  by 
heating  to  65°  C.  for  half  an  hour.  By  injection  of  the 
toxin  into  rabbits  an  antitoxic  serum  can  be  prepared, 
which  neutralizes  the  poison  in  vitro,  and  acts  prophy- 
lactically  against  injections  of  the  poison  in  animals.  The 
behaviour  of  vaccines  sensitized  by  immune  animal  serums 

1  Journ.  Amer.  Med.  Assoc.,  1913,  Ix.  289.     In  the  recent  epidemic 
outbreak  of  the  disease  in  England  many  prophylactic  inoculations 
have   been   carried   out,   the   value    of   which   it  is   impossible  to 
estimate  ;  and  equally  nebulous  are  the  results  of  the  vaccination  of 
contacts,  also  extensively  practised. 

2  Ann.  de  VInst,  Pasteur,  1900,  xiv.  331. 


390       SERUMS,    VACCINES,    AND    TOXINS 

seems  to  indicate  that  the  antitoxic  properties  of  such  serums 
are  inferior  to  their  bactericidal  powers. 

DIAGNOSIS 

Complement  -  fixation. — Different  conclusions  have 
been  reached  by  various  investigators  as  to  the  value  of  the 
complement-fixation  reaction  as  a  test  for  the  gonorrhceal 
infection.  Much  appears  to  depend  on  the  nature  of  the 
antigen  used.  Thus,  a  solution  of  gonococci  in  antiformin 
was  used  by  Merkurjew,1  a  suspension  of  the  organisms  in 
saline  solution  by  Romanow,2  and  a  similar  emulsion  by 
McDonagh  and  Klein.3  The  latter  probably  gives  the 
more  reliable  results,  but  will  not  keep  even  at  0°  C.  for 
more  than  ten  to  fourteen  days ;  the  emulsion  must  not  be 
concentrated,  and  an  emulsion  giving  a  count  of  300  to  500 
gonococci  per  cubic  centimetre  on  titration  will  be  found  to 
form  a  suitable  antigen. 

Teague  and  Torrey 4  observed  that  the  serum  of  an 
animal  immunized  to  one  strain  only  of  gonococcus  might 
fail  to  fix  complement  in  the  presence  of  an  antigen 
obtained  from  a  different  strain ;  hence  they  recommend  an 
emulsion  compounded  from  a  number  of  different  strains 
of  gonococci  as  antigen. 

McDonagh  and  Klein  regard  the  test  as  a  valuable  aid 
to  diagnosis,  while  Finkelstein  and  Gei'sham "'  find  it  useful 
in  chronic  cases,  and  Schwartz c  in  cases  complicated  by 
arthritis. 

Lenartowecz  7  states  that  a  positive  reaction  is  obtained 
in  80-83  per  cent,  of  cases  of  the  disease.  On  the  other 

1  Abstr.  in  Zeitschr.f.  Immunitatsforsch.,  1910,  p.  864. 
"*lbid.,  1913,  p.  803. 

3  Journ.  of  Path,  and  Bad.,  1913,  xvii.  559  ;  Proc.  Roy.  Soc.  Med., 
Path.  Sect.,  1912,  vi.  67. 

4  Journ.  Med.  Research,  1908,  xvii.  223. 

5  Abstr.  in  Zeitscltr.f.  Immunitiitsforsch.,  1912,  p.  243, 

6  Amer.  Journ.  Med.  Sci.,  1912,  cxliv.  369. 
<  J)ermntol.  Woch.,  1912,  p.  1179, 


GONORRHCEA  391 

hand,    O'Neil J    and   Watabiki 3   look   on   the   test  as  un. 
reliable. 

ClltaneOUS  reaction, — A  reaction  analogous  to  the 
von  Pirquet  test  in  tuberculosis,  obtained  by  inoculation  of 
a  glycerin  extract  of  the  cocci,  is  looked  upon  as  useful  by 
Irons,3  but  Seki,4  Dmitrijeff,5  Sakaguchi  and  Watabiki 6 
all  hold  that  it  is  of  no  value.  Attempts  to  constitute  an 
ophthalmic  test,  analogous  to  the  Calmette  reaction  for 
tubercle,  also  failed  in  the  hands  of  Motomura.7 

Vaccine  diagnosis, — The  administration  of  a  large 
dose  of  gonococcus  vaccine  may  be  used  for  diagnostic 
purposes,  being  followed  by  a  febrile  reaction  in  96  per 
cent,  of  cases  and  by  a  local  reaction  in  82  per  cent. 
(Fronstein),8  and  by  the  reappearance  of  a  positive  comple- 
ment-fixation reaction  in  the  patient's  serum.  Gonococci 
previously  absent  from  the  urethral  discharge  may  re- 
appear as  a  consequence  of  this  procedure.  Some  caution 
must  be  used  in  employing  this  test,  as  acute  swelling  of 
the  uterine  adnexa  may  ensue  in  women  (Van  der  Velde).9 

The  authors  find  the  most  valuable  application  of  this 
test  in  settling  the  question  whether  or  not  a  patient  who 
has  suffered  from  gonorrhoaa  should  be  permitted  to  marry. 

TREATMENT 

Serum  treatment. — Rogers  and  Torrey  10  prepared  a 
serum  by  injecting  rams  first  with  heated  and  then  with 
fresh  cultures  of  the  gonococcus.  They  found  it  useless 

1  Boston  Med.  and  Surg.  Journ.,  1912,  clxvii.  464  ;    Med.  Record, 
1910,  Ixxviii.  599. 

2  Journ.  Infect.  Sis.,  1910,  vii.  159. 

3  Journ.  Amer.  Med.  Assoe.,  1912,  Iviii.  931. 

4  Abstr.  in  Zeitschr.f.  Immunitatsforsch.,  1910,  p.  989. 

5  Ibid.,  1913,  p.  253. 

6  Dermatol.  Woch.,  1912,  p.  717. 

7  Abstr.  in  Zeitschr.f.  Immunitatsforsck.,  1913,  p.  772. 
s  Ibid.,  1913,  p.  251. 

9  Ibid.,  1912,  p.  538. 
10  Journ.  Amer.  Med,  Assoc.,  1907,  xlix. ,  No.  11. 


392       SERUMS,    VACCINES,    AND    TOXINS 

as  a  remedy  in  urethritis  and  conjunctivitis — localized 
lesions — but  of  some  value  in  gonorrhceal  septicaemia. 
Uhle  and  Mackinney1  also  record  that  serum  treatment 
is  useful  in  gonorrhceal  arthritis,  but  ineffective  against 
the  urethritis  caused  by  the  gonococcus. 

Bemskaia2  prepared  a  serum  by  injecting  a  goat  with 
gonococci,  and  found  it  of  some  use  in  treatment,  although  it 
appeared  only  to  inhibit  the  development  of  the  organisms 
rather  than  to  kill  them.  The  use  of  serum  for  gonorrhoeal 
rheumatism  is  practised  by  L.  E.  Schmidt,3  quantities  of 
2,  4,  6,  8  c.c.  and  so  forth  being  administered  every  five 
days ;  and  good  results  in  this  affection,  as  well  as  in 
orcbitis,  epididymitis,  and  cardiac  complications,  are  re- 
corded by  Horwitz.4  The  authors  regret  that  in  their 
own  experience  they  have  never  yet  seen  any  beneficial 
effect  follow  the  use  of  antigonococcic  serums. 

Vaccine  treatment. — In  cases  of  gonococcal  ure- 
thritis of  a  subacute  type  the  opsonic  index  is  usually 
low  (0'6) ;  in  those  which  rapidly  convalesce  it  is  high 
(1"8)  ;  whilst  in  those  which  merge  into  an  intractable  gleet 
it  varies  almost  from  day  to  day,  within  wide  limits.  Many 
writers  regard  vaccine  treatment  as  inapplicable  to  the 
acute  stages  of  the  local  disease,  though  Palmer'"'  advises 
the  use  of  small  doses  in  this  condition,  and  there  is 
evidence  that  such  treatment  may  relieve  pain.  On 
the  other  hand,  there  is  a  consensus  of  opinion  as  to 
the  value  of  vaccines  in  localized  complications  such  as 
epididymitis,  orchitis,  prostatitis,  and  iritis ;  whilst  in 
severe  cases  of  gonorrhoeal  sapraemia  or  septicaemia  with 
pyrexia  and  prostration  the  effect  of  vaccines  is  most 
marked.  Vaccination  does  not,  according  to  Iljinsky,6  pre- 

1  Journ.  Amer.  Ned.  Assoc.,  July  11,  1908. 

2  Abstr.  in  Zeitschr.f.  Immunitatoforseh.,  1913,  p.  945. 

3  lied.  Record,  1910,  Ixxviii.  600. 

4  Ibid.,  1911,  Ixxx.  747. 

5  Ibid.,  1911,  Ixxix.  337. 

6  Abstr.  in  Zeittchr.f.  Immunitatsforsch.,  1914,  p.  1074. 


GONORRHCEAL   VACCINES  393 

vent  the  occurrence  of  metastatic  inflammation — a  feature 
also  noted  in  regard  to  tuberculin. 

It  is  generally  conceded  that,  in  gonorrhoea,  stock 
vaccines  are  as  useful  as  autogenous,  though  O'Neil  recom- 
mends the  latter  in  cases  of  arthritis.  A  stock  vaccine 
under  the  trade  name  of  "Arthigon"  has  enjoyed  a  certain 
vogue,  also  another  termed  "  Dmegon,"  stated  to  be  a 
mixed  vaccine  of  the  gonococcus  and  a  "  syncoccus " — by 
which  term  is  probably  meant  Staphylococcus  albus,  so 
frequently  associated  with  the  specific  organisms  in  urethral 
discharges.  In  our  hands  the  use  of  these  proprietary 
vaccines  in  a  long  series  of  cases  (with  one  notable 
exception  which  was  rapidly  cured  apparently  by  Dmegon) 
has  been  followed  by  distinctly  unfavourable  results.  In 
any  case  the  vaccines  should  not  be  kept  for  more  than  three 
months  (Klause),1  as  they  undoubtedly  deteriorate  more 
rapidly  in  immunizing  value  than  most  bacterial  vaccines. 

Eyre  and  Stewart 2  advise  that  in  the  acute  stage, 
whenever  possible,  autogenous  vaccines  should  be  em- 
ployed ;  but  if  such  a  course  is  impossible,  polyvalent 
stock  vaccines,  prepared  from  five  or  ten  different  strains 
of  gonococci,  must  be  used.  Of  these  the  initial  doses 
should  not  exceed  5  millions.  With  such  a  dose  the 
negative  phase  is,  as  a  rule,  short,  and  is  marked  clini- 
cally by  exacerbation  of  the  discharge,  which  lasts  from 
one  to  three  days,  and  is  followed,  as  the  positive  phase 
becomes  established,  by  a  rapid  diminution.  After  a  second 
injection  this  sequence  of  events  is  repeated,  but  with  a 
less  marked  negative  phase.  Urethral  irrigation  should  at 
first  be  forbidden.  Later,  when  the  patient  has  shown  a 
satisfactory  response  to  the  inoculations,  irrigation  of  the 
urethra  with  some  simple  aseptic  solution,  such  as  potas- 
sium permanganate,  1  :  1,000,  should  be  instituted,  and 
it  will  usually  be  found  that  after  a  few  days  the  dis- 
charge entirely  ceases. 

i  BerL  Jclin.  Woeh.,  1913,  xxxix.  1813. 
8  Lancet,  1909,  ii.  76. 


394       SERUMS,    VACCINES,    AND   TOXINS 

Sensitized  vaccines  (dead)  prepared  from  autogenous  or 
stock  cultures  of  the  gonococcus  have  proved  very  efficacious 
in  our  hands,  but  the  sensitization  must  be  effected  either 
with  human  serum  or  with  the  serum  of  an  animal 
immunized  to  that  particular  strain  employed  for  the  vac- 
cine. McDonagh  and  Klein  l  have  also  laid  stress  on  these 
points.  These  authors  have  besides  reported  favourably  on 
the  use  of  autolysed  stock  vaccines  injected  intravenously 
the  dose — usually  a  small  one  of  1  to  5  millions — being 
distributed  in  some  10  c.c.  of  normal  saline  solution  prior 
to  administration. 

One  point  of  considerable  importance  must  be  insisted 
upon,  namely,  that  cases  of  chronic  gleet  of  many  years' 
standing  are  frequently  not  benefited  by  gonococcus  vaccine. 
The  gonococcus  in  such  cases  appears  to  have  died  out,  and 
various  staphylococci  and  streptococci,  often  of  very  low 
virulence,  are  now  responsible  for  the  persistence  of  the 
"  morning  drop,"  and  the  administration  of  a  vaccine 
prepared  from  such  organisms  rapidly  results  in  a  cure. 

Eyre  and  Stewart2  have  summarized  the  vaccine  treat- 
ment of  gonococcus  infections  as  follows  : — 

"I.  Acute  gonorrhoea. — 1.  Gonococcus  vaccine  is  markedly  toxic 
and  exerts  a  profound  influence  over  the  disease. 

"  2.  For  routine  work  (hospital  out-patients,  etc.)  vaccine  treatment 
is  not  devoid  of  danger  and  requires  the  exercise  of  considerable 
caution. 

"  3.  A  stock  vaccine,  comprising  a  dozen  different  strains,  gives 
results  only  slightly  inferior  to  those  observed  when  using  a  vaccine 
prepared  from  the  patient's  own  organism.  This  is  not  the  rule  in 
most  other  diseases. 

"4.  Small  doses,  repeated  at  short  intervals,  are  more  effective 
than  large  doses  at  lengthened  intervals. 

"  5.  Small  doses  of  vaccine  (from  1,000,000  to  10,000,000  cocci)  are 
safer  and  more  satisfactory  than  the  large  doses  (from  50,000,000  to 
100,000,000)  which  are  often  prescribed. 

"  6.  After  an  injection  of  from  500,000  to  2,000,000  the  negative 
phase  is  either  absent  or  extremely  transient. 

1  Journ.  o/PatJi.  and  Bact.,  1912,  xvii.  559. 
a  Op.  tit 


GONORRHCEAL    VACCINES  395 

"  7.  An  inoculation  of  from  5,000,000  to  10,000,000  causes  a  nega- 
tive phase  of  usually  not  longer  than  forty-eight  hours'  duration, 
followed  by  a  positive  phase  of  from  three  to  five  days. 

"  8.  Vaccine  in  small  doses  serves  the  double  purpose  of  raising  and 
steadying  the  opsonic  index.  A  steady  index  just  above  normal  is 
found  to  be  the  most  favourable  condition  for  rapid  recovery. 

"  II.  Simple  chronic  gonorrhoea. — 1.  Where  the  gonococcus  has 
ceased  to  be  the  infecting  organism,  these  cases  are  on  a  par  with 
other  chronic  inflammatory  states,  but  are  frequently  more  difficult 
to  cure  owing  to  environment  and  local  conditions. 

"  2.  Chronic  cases,  where  the  gonococcus  is  the  sole  infecting 
organism,  have  a  better  prognosis  from  the  point  of  view  of  treatment 
by  vaccine  than  a  mixed  infection  or  one  of  staphylococcus  only. 

"III.  Chronic  gonorrhoea  ^vith  complications. —  1.  The  estimation  of 
the  opsonic  index  is  helpful  to  diagnosis,  and  is  a  useful  means  of 
determining  approximately  the  opsonic  state  of  the  blood.  Chronic 
gonococcus  infections,  however,  present  clinical  features  which  them- 
selves afford  valuable  indications  during  the  course  of  vaccine 
treatment. 

"  2.  Where  the  gonococcus  alone  is  the  infecting  organism,  if  the 
opsonic  index  cannot  be  obtained  as  frequently  as  is  desirable, 
routine  injections  of  from  1,000,000  to  2,000,000  cocci  every  three  to 
five  days  are  safe  and  satisfactory  ;  a  lapse  of  five  to  seven  days  after 
doses  of  5,000,000  ;  an  interval  of  eight  to  ten  days  after  inoculation 
of  10,000,000.  Larger  doses  than  these  are  seldom  desirable. 

"  3.  Treatment  by  small  and  gradually  increasing  doses  at  frequent 
intervals  should  at  all  times  be  preferred ;  the  use  of  large  doses  is  even 
more  dangerous  than  in  acute  cases,  and  may  be  followed  by  disastrous 
consequences. 

"  4.  In  orchitis  small  doses  of  vaccine  quickly  relieve  pain  and 
cause  a  more  rapid  abatement  of  symptoms  than  is  obtained  by  the 
usual  routine  treatment  alone. 

"  5.  In  iritis  the  severe  pain,  which  is  a  marked  and  obstinate 
feature,  is  relieved  in  forty-eight  hours  after  an  injection,  and  dis- 
appears in  from  three  to  four  days ;  cure  is  much  hastened. 

"  6.  In  arthritis  the  treatment  is  of  considerable  value." 

MEDITERRANEAN   OR  UNDULANT  FEVER 

Etiology. — This  disease  is  due  to  a  minute  oval  coccus, 
the  Micrococcus  melitensis,  discovered  by  Bruce  in  1888. 

Paramelitensis  fever  is  said  to  be  due  to  a  variant  of 
M.  melitensis,  an  organism  which  differs  from  M.  meliten- 
sis,  according  to  some  observers,  in  its  serum-reactions. 


396       SERUMS,    VACCINES,    AND   TOXINS 

Working  with  various  strains  of  p;irarneliterisis  supplied  to 
us  by  Nicolle,  we  have  been  unable  to  satisfy  ourselves  of 
the  existence  of  real  differences. 

Agglutination. — The  micrococci  are  agglutinated  by 
the  serum  of  sufferers  from  the  fever.  The  reaction  may 
appear  as  early  as  the  fourth  day,  seldom  later  than 
the  sixth,  and  occurs  in  considerable  dilutions  (1  :  100, 
1  :  1,000,  up  to  1  :  5,000).  This  reaction  is  very  valu- 
able as  a  means  of  diagnosis,  but  certain  precautions 
must  be  observed  in  carrying  it  out.  The  culture  of  M. 
melitensis  must  be  one  recently  isolated,  or  one  recently 
passed  through  the  body  of  an  animal,  and  stable  so  far  as 
concerns  non-specific  serum ;  the  reaction  must  be  positive 
in  dilutions  of  1  :  100  at  least;  and  the  frequent  occur- 
rence of  inhibition  zones  or  paradoxical  reactions  must  be 
remembered,  for  it  is  quite  common  to  observe  a  positive 
reaction  in  dilutions  of  1  :  50  or  1  :  100  of  a  serum  which 
fails  to  agglutinate  the  coccus  in  dilutions  of  1  :  10  and 
1  :20. 

The  phenomenon  of  complement-fixation  was  obtained 
by  Saisawa1  with  the  serum  of  patients,  the  antigen  used 
being  an  extract  of  the  cocci.  For  practical  purposes  of 
diagnosis  it  is  not  likely  to  supersede  the  agglutination  test. 

Serum  treatment. — Wright  and  Semple2  have  treated 
one  case  of  this  disease  with  a  curative  serum.  The  mode 
of  preparation  of  this  is  not  stated,  nor  can  trial  in  a  single 
case  afford  any  trustworthy  evidence  of  the  value  of  the 
remedy. 

Eyre3  also  prepared  a  serum  from  a  horse,  which 
agglutinated  in  dilutions  of  1  :  3,000  to  1  :  5,000,  and  had 
some  prophylactic  power ;  but  it  did  not  prove  very 
effective  as  a  remedy  for  the  disease. 

A  serum  prepared  in  Italy,  and  known  as  Trambusti's 
or  Trambusti  and  Donzello's  serum,  has  been  found  useful 

1  ZeitscJtr.f.  H,jg.,  1912,  Ixx.  177. 

-  Lancet,  1899,  i.  1024. 

3  Kept.  Medit.  Fever  Commiss.,  1907,  Parts  v.,  vi. 


MEDITERRANEAN   FEVER  307 

by  Tomaselli,1  Natale,2  Cantieri,3  and  others,  but  the  cases 
which  they  record  are  far  from  convincing. 

Vaccine  treatment. — Reid4  used  therapeutic  inocula- 
tions, controlled  by  estimations  of  the-  opsonin-index,  as  a 
mode  of  treatment,  with  good  results.  Basse  tt-Smith"'  also 
prepared  a  vaccine  by  heating  agar-cultures  of  the  micro- 
coccus  to  60°  C.  for  half  an  hour,  but  did  not  find  it 
efficacious  in  the  treatment  of  the  disease. 

Kennedy,6  who  states  that  agglutination  is  usually 
absent  in  chronic  cases — pointing,  perhaps,  to  lack  of  forma- 
tion of  other  antibodies — finds  autogenous  vaccines  useful, 
the  fever  tending  to  fall  and  the  agglutinins  to  appear  in 
the  blood  after  this  treatment.  He  gives  an  initial  dose  of 
100  millions  of  cocci,  followed  by  smaller  doses  of  6,  7^,  or 
9  millions. 

We  have  obtained  excellent  results  in  a  number  of 
cases  by  the  employment  of  autogenous  vaccines  in  small 
doses,  ^  to  1  million  cocci,  repeated  at  intervals  of  four  to 
five  days  and  gradually  increased  to  5  and  10  millions. 

Eyre7  employed  similar  vaccines  in  doses  of  200,  300,  or 
400  millions  for  prophylaxis,  and  considered  that  some 
protection  was  thereby  afforded. 

1  Gaz.  degli  Ospedali,  1912,  xxxiii.  457. 

2  Eiv.  Grit.  Clin.  Med.,  1912,  xiii.  787. 

3  Ibid.,  1915-16,  pp.  289,  305,  321. 

4  Ann.  Sept.  Sanit.  Com.  with  the  Govt.  of  India  for  1905,  p.  153. 

5  Journ.  of  Hyg.,  1907,  vii.  115. 

6  Journ.  Roy.  Army  Med.  Corps,  1910,  xv.  317. 

7  Sept.  Medit.  Fever  Commits.,  1907,  Part  vi.,  p.  115. 


CHAPTER   XX 

CATARRHAL    AFFECTIONS 

HAY-FEVER 

Etiology. — Not  only  the  peculiar  specific  affection  con- 
nected with  the  pollen  of  certain  grasses,  but  also  nervous 
conditions  of  an  asthmatic  type,  occurring  in  the  summer 
months,  are  probably  often  included  under  the  name  of  hay- 
fever.  Dunbar  ]  has  satisfactorily  proved  that  the  pollen  of 
rye  and  other  grasses  is  responsible  for  true  hay-fever.  The 
pollen-grains  contain  a  soluble  toxin  which  is  capable  of 
affecting  susceptible  persons,  whereas  normally  constituted 
individuals  suffer  no  ill  effects  from  it.  Dunbar's  experi- 
ments were  as  follows  :  He  took  the  pollen  of  rye  and 
applied  it  to  the  nostrils  of  a  certain  number  of  persons 
who  suffered  periodically  from  hay-fever,  and  also  to  those 
of  others  who  had  not  experienced  the  disease.  In  the 
former  definite  symptoms  of  coryza  and  irritation  of  the 
nasal  mucous  membrane  were  produced ;  while  the  latter 
did  not  exhibit  any  ill  effects.  Similar  results  were  pro- 
duced in  susceptible  persons  by  applying  the  pollen  to  the 
conjunctivse.  That  the  symptoms  were  not  due  to  the 
mechanical  effects  of  the  grains  of  pollen  was  proved  by 
control  experiments  with  materials  derived  from  other 
plants,  including  those  varieties  which  have  pollen-grains 
of  a  prickly  form.  Of  two  persons  who  were  placed  in  a 
room  and  caused  to  blow  into  a  vessel  containing  the 
toxic  pollen,  one  who  was  susceptible  to  hay-fever  exhibited 
symptoms  of  bronchitis  and  asthma,  while  the  other  was 
unaffected. 

1  "Zur  L'rsache  und  Specifischen  Heilung  des  Heufiebei>-,"  1903, 
and  Dent.  med.  JToch.,  1903,  No.  9. 

898 


HAY-FEVER   ANTITOXIN  390 

The  soluble  nature  of  the  toxin  was  demonstrated  by 
making  aqueous  and  ethereal  extracts  of  the  pollen  and 
applying  them  in  the  same  way  to  patients.  Symptoms  of 
hay -fever  were  invariably  produced  in  susceptible  persons. 
If  the  pollen  is  kept  for  any  length  of  time,  so  that  it 
becomes  dry,  it  no  longer  induces  symptoms  ;  but  if  the 
dried  grains  are  broken  up,  the  toxic  effects  are  again 
manifested.  In  ordinary  cases  it  seems  that  the  poison  is 
dissolved  out  by  the  tears  and  nasal  secretion,  and  is  thus 
enabled  to  act.  Dunbar  found  that  symptoms  of  irritation 
were  produced  by  application  of  the  toxic  pollen  to  other 
mucous  surfaces  besides  those  of  the  eye  and  nose,  e.g.  by 
application  to  the  anus.  If  a  solution  of  the  poison  is 
injected  hypodermically,  very  similar  effects  are  produced 
to  those  seen  after  its  local  application.  Thus,  a  medical 
man,  subject  to  attacks  of  hay-fever,  received  an  injection 
hypodermically  in  the  arm.  He  first  felt  giddy,  and  in  a 
quarter  of  an  hour  was  seized  with  sneezing,  cough,  lachry- 
niation,  soreness  of  the  throat,  and  dyspnrea.  The  face 
swelled  and  the  voice  became  hoarse ;  there  was  respiratory 
stridor,  and  by  laryngoscopical  examination  the  vocal  cords 
were  seen  to  be  congested.  The  frequency  of  both  pulse 
and  respii-ation  was  increased.  A  cutaneous  eruption  en- 
sued, of  an  urticarial  nature,  with  great  itching ;  the  arm 
in  which  the  injection  was  given  became  markedly  swollen. 
A  second  subject,  who  did  not  suffer  from  hay -fever 
exhibited  no  ill  effects  from  a  similar  injection. 

It  has  been  suggested  that  the  phenomena  of  hay-fever 
are  analogous  to  those  of  anaphylaxis. 

Antitoxin. — Dunbar  proceeded  to  attempt  the  manu- 
facture of  an  antitoxin  to  counteract  the  toxin  contained 
in  the  pollen.  He  injected  the  latter  into  rabbits,  and  used 
their  serum  for  experiments.  He  found  that  the  serum 
obtained  from  these  animals  was  capable  of  neutralizing  the 
toxin  and  protecting  susceptible  persons  from  its  effects. 
Thus,  if  some  of  the  serum  were  added  to  the  toxin,  the 
mixture  could  be  introduced  into  the  eye  of  a  susceptible 


400       SERUMS,    VACCINES,    AND    TOXINS 

person  without  any  ill  effects.  Serum  from  a  normal 
rabbit  had  no  protective  action. 

Several  other  writers  confirm  Dunbar's  results.  Semon  l 
tried  the  serum,  and  found  that  definite  effects  were  pro- 
duced. It  cannot  be  described  as  curative  of  the  disease, 
but  considerable  improvement  results  from  its  use.  The 
effects  differ  considerably  in  different  cases.  If  the  serum 
be  applied  to  the  nose  and  eyes,  when  the  first  symptoms 
are  experienced  which  are  known  by  the  patients  to  portend 
an  attack  of  hay-fever,  the  threatened  access  may  be 
aborted.  In  some  cases  the  remedy  unaccountably  fails.  The 
subjective  relief  produced  in  patients  is  often  greater  than 
the  diminution  in  the  objective  signs  of  the  disease.  The 
duration  of  the  relief  afforded  is  not  long,  and  repeated 
instillations  of  the  antitoxin  are  required.  Subcutaneous 
injections  are  not  advisable,  as  the  local  oedema  produced 
is  considerable,  and  the  amount  of  protection  gained  is 
uncertain. 

M'Bride,2  too,  is  favourably  disposed  towards  the  use 
of  the  serum.  He  concludes  that  Dunbar  has  definitely 
succeeded  in  isolating  the  toxin  of  the  disease  and  in 
producing  an  antitoxin  capable  of  neutralizing  it.  It  is 
doubtful,  however,  whether  it  is  the  pollen  of  grasses  alone 
which  is  responsible  for  the  disease,  and  therefore  whether 
we  possess  in  the  serum  an  antidote  to  all  forms  of  hay- 
fever.  Some  persons  suffer  from  a  similar  catarrhal  con- 
dition if  they  are  exposed  to  the  smell  of  horses  or  cats, 
and  it  is  evident  that  the  serum  prepared  from  pollen 
cannot  be  expected  to  act  beneficially  in  such  cases. 
Knight3  collected  219  cases  in  which  the  serum  was  used  ; 
of  these  114  show  great  improvement  and  66  slighter  benefit. 

Thost 4  also     confirms    Dunbar's     results,   but  remarks 

1  Brit.  Med.  Journ.,  1903,  ii.  123,  220. 

2  Edln.  Med.  Journ.,  1903,  ii.  7. 
Med.  Record,  March  10,  1906. 

4  Munch,  med.  ll'och.,  June  9, 1903.  Cf.  Lubbert,  TJieraj).  Monatth., 
Dec.,  1904. 


AUTUMN    CATARRH  401 

that  in  all  cases  of  hay-fever  there  is  a  certain  element  of 
nerve-weakness,  which  cannot  be  influenced  by  the  serum ; 
while  the  cases  which  are  complicated  by  morbid  local 
conditions  will  need  appropriate  treatment  for  these,  as  well 
as  the  specific  remedy. 

Weichardt :  points  out  that  in  many  cases  the  serum  may 
do  good  at  first,  but  is  afterwards  not  tolerated.  We  have 
seen  a  certain  number  of  instances  in  which  it  seemed  to 
afford  relief,  but  seldom,  if  ever,  a  result  that  could  be  de- 
scribed as  a  cure.  Nevertheless  the  remedy  is  well  worthy 
of  trial  in  severe  cases  of  the  affection. 

Autumn  catarrh. — In  the  United  States  of  America 
there  is  a  form  of  hay-fever,  known  as  "autumn  catarrh," 
which  appears  in  the  autumn,  at  a  time  when  there  is  no 
pollen  from  rye  in  the  air.  It  seems  necessary  to  suppose 
that  these  cases  are  due  to  a  different  cause.  Dunbar  3  has 
investigated  some  of  the  plants  which  might  be  responsible 
for  such  autumnal  cases,  and  finds  that  golden-rod  and  rag- 
weed contain  toxins  capable  of  exciting  the  disease.  The 
toxin  is  not  the  same  body  as  that  found  in  grass-pollen, 
but  the  antitoxin  prepared  for  the  latter  is  capable  of 
neutralizing  it  to  some  extent.  Dunbar  considers  that  this 
action  is  comparable  with  the  agglutinative  action  which 
the  serum  of  a  patient  suffering  from  one  disease  may  at 
times  exert  on  bacteria  other  than  the  causal  organism 
but  belonging  to  the  same  group. 

Dunbar  adds  some  reasons  for  the  want  of  success 
which  at  times  attends  the  use  of  the  serum  as  a  cure  for 
hay-fever.  Patients  often  insist  on  sleeping  with  their 
windows  open,  and  in  otherwise  exposing  themselves  to 
repeated  infection  with  the  toxin.  They  should,  on  the 
contrary,  refrain,  from  walks  in  the  country  at  the  times 
when  they  are  liable  to  the  disease,  and  generally  avoid  all 
opportunities  of  reinfection. 

Dunbar's  serum. — This  is  now  prepared  from  horses, 

1  Abstr.  in  Ccntralbl.  f.  Baltt.,  1906,  xxxviii.  493. 

2  Berl.  Wn.  Woch.,  July  13,  1903. 
2A 

IzlE   Olr   US 


402       SERUMS,    VACCINES,    AND    TOXINS 

and  is  to  be  obtained  commercially.  It  is  called  "  pollan- 
tin,"  and  is  sent  out  in  small  cases  containing  a  bottle  of 
the  antitoxin  and  a  drop-pipette  for  applying  it.  The 
following  directions  l  for  its  use  are  supplied  : — 

"  As  the  serum  would  soon  be  contaminated  by  frequent 
contact  with  the  pipette,  it  is  advisable  to  pour  out  one- 
third  of  the  contents  of  the  serum  phial  into  the  empty 
glass  provided  with  a  drop-pipette.  This  glass  is  effectually 
closed  by  pressing  the  indiarubber  cap  of  the  pipette  into 
it,  but  care  should  be  taken  to  keep  this  glass  upright,  so  as 
to  avoid  the  liquid  flowing  into  the  cap.  Patients  should 
not  fail  to  carry  a  small  quantity  of  serum  in  this  glass 
about  with  them  whenever  they  may  expect  a  hay-fever 
attack.  Immediately  after  noticing  the  first  symptoms  of 
irritation  in  nose  or  eye,  a  drop  or  two  of  the  serum  should 
be  instilled  upon  the  eye  or  into  the  nose  affected. 

"  The  serum  can  be  applied  to  the  eye  in  the  following 
manner  :  After  sucking  up  a  few  drops  into  the  pipette, 
exert  a  gentle  pressure  on  the  rubber  cap  until  one  drop 
just  emerges  from  the  opening  of  the  pipette  ;  then  before 
a  mirror  carefully  approach  the  pipette  to  the  outer  corner 
of  the  eyelid,  when  the  drop  is  sucked  up  by  the  eyelashes, 
and  spreads  over  the  conjunctival  membrane.  By  the  aid 
of  a  pocket  mirror  the  same  manipulation  can  easily  be 
carried  out  in  the  open  air. 

"  In  order  to  instil  the  serum  into  the  nasal  cavity,  fill 
the  pipette  with  three  or  four  drops  of  serum,  and,  bending 
your  head  backwards,  insert  the  pipette  about  |-  in.  into  the 
nostril  affected,  and  empty  it  by  a  short  pressure  on  the 
rubber  cap.  A  few  sniffs  suffice  to  spread  the  serum  over 
the  mucous  membrane." 

Ophthalmic  test. — Noon2  devised  an  ophthalmic 
test  for  hay-fever  on  the  lines  of  Calmette's  ophthalmo- 
reaction  for  tuberculin,  by  extracting  1  grm.  of  the  pollen 
of  Phleum  pratense  in  50  c.c.  of  water,  to  which  he  gives 

1  From  Semon's  article  in  the  Brit  Med.  Journ..  1903,  ii.  124. 

2  lancet,  1911,  i.  1572. 

1  J 


NASAL   CATARRH  403 

an  arbitrary  value,  stating  that  it  contains  20,000  pollen 
units  per  c.c.  From  this  varying  dilutions  are  prepared  in 
strengths  of  from  5  to  5,000  units.  The  healthy  individual 
yields  no  reaction  whatever,  even  when  a  few  drops  of 
the  dilution  of  5,000-unit  strength  are  instilled  into  the 
conjunctival  sac ;  conversely,  most  sufferers  from  true  hay- 
fever  will  give  a  positive  reaction  (tickling  sensation  at 
inner  canthus,  reddening  of  the  caruncle,  or  finally  injec- 
tion of  the  entire  bulbar  conjunctiva,  lachrymation,  and 
sneezing)  even  with  the  5-unit  dose. 

Vaccine  treatment. — Further  experiments  showed 
that  immunization  against  the  toxins  of  a  number  of 
different  pollens  could  be  effected  by  the  subcutaneous 
inoculation  of  increasing  doses  of  the  pollen-extract  or 
vaccine,  the  injections  as  to  time  and  dose  being  controlled 
by  means  of  the  ophthalmo-reaction.  Freeman1  records 
satisfactory  results  in  16  patients  out  of  20  treated,  and 
later2  gives  details  of  64  additional  cases]  he  is  convinced 
of  the  value  of  the  method.  The  pollen-vaccine  may  be 
used  both  as  a  remedy  and  as  a  prophylactic  measure. 
Personally  we  prefer  it  in  its  latter  aspect,  and  find  that 
treatment  commenced  in  February  or  March  gives  the  most 
satisfactory  results. 

NASAL  CATARRH 

Allen 3  states  that  "  a  cold  in  the  head  "  or  coryza  may 
be  due  either  to  Friedlander's  bacillus,  to  the  Micrococcus 
catarrhalis,  or  to  B.  septus.  Vaccine  treatment  may  cure 
chronic  colds,  and  may  prevent  recurrence  in  persons  who 
are  prone  to  them.  He  uses  a  vaccine  consisting  of  150 
millions  of  M.  catarrhalis  in  cases  due  to  this  organism 
(which  may  also  be  responsible  for  tracheal  catarrh).  Our 
own  experience  suggests  that  it  is  advisable  to  prepare  the 
vaccine  from  the  organism  derived  from  the  individual 

1  Lancet,  1911,  ii.  814. 

2  Ibid.,  1914,  i.  1178. 

3  Hid.,  1909,  ii.  1589,  1659. 


404       SERUMS,   VACCINES,    AND    TOXINS 

patient,  and,  when  the  cure  is  complete,  to  administer  two 
or  three  doses  of  a  stock  vaccine  compounded  of  the  various 
bacteria  which  may  be  responsible  for  acute  and  chronic 
catarrh — viz.  Bacillus  influenzce,  B.  septus,  B.  pneumonia', 
Micrococcns  catarrhalis,  and  M.  pneumonic? — as  a  prophy- 
lactic measure.  We  are  convinced,  too,  that  the  dose 
above  recommended  is  too  large,  and  rarely  give  more  than 
25  (or  50  at  the  outside)  millions  during  the  course  of 
treatment,  or  more  than  100  millions  for  prophylaxis. 

In  many  instances  the  duration  of  the  immunity  so 
produced  is  brief,  and  patients  may  need  two  or  three 
prophylactic  doses  every  autumn.  On  the  other  hand, 
individuals  previously  subject  to  chronic  catarrh  may 
acquire,  as  a  result  of  vaccine  treatment,  freedom  from  this 
form  of  infection  for  a  period  extending  to  six  years. 


CHAPTER  XXI 
DISEASES   DUE   TO   PROTOZOA 

SYPHILIS 

Etiology. — It  is  now  generally  accepted  that  the  causal 
organism  of  syphilis  is  the  spirochsete  discovered  by  Schau- 
dinn,  and  known  as  the  Treponema  pallidum  (Spirochceta 
pallida),  a  protozoon  which  has  been  grown  in  pure  culture 
in  artificial  media  by  Noguchi. 

Serum  reaction  in  syphilis. — The  appearance  of 
the  Bordet-Gengou  phenomenon  of  complement -fixation 
(see  Chapter  IV.,  p.  89)  in  syphilitic  infection  was  first 
brought  forward  as  a  practical  means  of  diagnosis  in  the 
communication  from  Wassermann,  Neisser,  and  Bruck,1  in 
May,  1906.  The  work  on  which  this  was  founded  was 
done  on  Neisser's  apes,  artificially  inoculated  with  syphilis. 
Immediately  afterwards,  and  independently,  Detre2  tried 
the  test  on  human  patients,  finding  a  positive  reaction  in 
2  out  of  6  cases.  Further  observations  tending  to  sub- 
stantiate the  value  of  the  method  were  afterwards  pub- 
lished by  Wassermann  and  Plaut.3  Later,  Morgenroth  and 
Stertz4  found  positive  reactions  in  the  cerebro- spinal  fluid 
of  general  paralytics,  Schutze  5  in  tabes  dorsalis,  and  Bab  G 
in  the  milk  of  syphilitic  women. 

The  antigen  originally  used  by  Wassermann  and  his 
collaborators  was  a  watery  solution  of  the  organs  of 

1  Deut.  med.  Woch.,  1906,  p.  745. 

2  Wien.  klin.  Woch.,  1906,  ix.  619. 

s  Berl.  lilin.  Woclt.,  1907,  Nos.  50  and  51. 

4  Virchow's  Archiv,  1907,  clxxxvii.  166. 

5  Berl.  kiln.  Woch.,  1907,  xliv.  126. 

*  Centralbl.  f.  Bakt.,  I.  Orig.,  1909,  li.  250. 
405 


406       SERUMS,    VACCINES,    AND    TOXINS 

syphilitic  apes  or  of  those  of  congenitally  syphilitic  chil- 
dren, or  alternatively  extracts  of  condyloraata  or  syphilitic 
placentae.  Weygandt  found  that  watery  extracts  of  normal 
organs  might  act  equally  effectually  as  an  antigen ;  while 
Landsteiner,  Miiller,  and  Potzl  tried  alcoholic  extracts  of 
syphilitic  material,  and  Meier  similar  extracts  of  normal 
organs,  with  success.  It  is  plain  from  these  findings  that 
the  reaction  is  not  a  specific  immune  reaction  between 
antigen,  copula,  and  complement  as  in  haemolysis,  since  the 
antigen  may  be  obtained  from  normal  as  well  as  from 
syphilitic  tissues,  and  is  not  a  specific  product  of  the  action 
of  the  Spiroch.ff.ta  pallida  or  a  protein  derived  from  the 
bodies  of  these  organisms.  Cholesterin  and  lecithin  are 
each  said  to  be  capable  of  taking  the  place  of  the  antigen, 
and  it  is  generally  supposed  that  some  lipoid  body  is  the 
substance  normally  at  work.  The  exact  nature  of  the 
reaction  must  at  present  remain  in  doubt. 

According  to  Wassermann's  technique  the  haemolytic 
copula  used  is  obtained  by  inoculating  a  rabbit  intraperi- 
toneally  with  washed  sheep's  corpuscles ;  the  animal  is 
then  bled  to  death  when  sufficient  injections  have  been 
administered,  the-  blood  defibrinated  and  centrifugalized, 
and  the  serum  kept  on  ice.  Before  use  it  is  heated  for 
half  an  hour.  Fresh  guineapig's  serum  serves  as  the 
source  of  complement.  Washed  sheep's  corpuscles  are 
suspended  in  normal  saline  so  as  to  form  a  5  per  cent. 
emulsion  (by  bulk).  The  antigen  is  obtained  by  mincing 
up  syphilitic  material,  adding  4—5  c.c.  of  saline  fluid  (con- 
taining 0'4  per  cent,  of  phenol)  to  each  gramme  of  minced 
material,  shaking  for  twenty-four  hours,  centrifugalizing, 
and  decanting  the  clear  fluid.  The  patient's  serum  is 
heated  for  half  an  hour  to  56'  C.  before  use.  An  antigen 
commonly  used  at  the  present  time  is  obtained  by  mincing 
up  normal  heart^muscle  (human  or  guineapig)  and  shaking 
with  alcohol  (10  c.c.  to  1  grm.) ;  the  fluid  extract  is 
diluted  with  9  parts  of  saline  before  use. 

The  technique   of  the  procedure  is   as   follows  :     The 


WASSERMANN'S    REACTION  407 

serum  from  the  patient,  previously  inactivated  by  heat- 
ing (therefore  containing  only  immune  body),  mixed  with 
liver-extract  and  a  small  quantity  of  fresh  serum  from 
the  guineapig  (to  provide  complement),  is  incubated  at 
37°  C.  for  one  hour ;  to  it  are  then  added-  sensitized  red 
cells  (i.e.  red  cells  mixed  with  their  appropriate,  but  in- 
activated, hsemolytic  serum),  and  the  mixture  is  again 
incubated  for  an  hour  at  37°  C.,  removed  to  an  ice-chest, 
and  allowed  to- stand  for  several  hours  before  examination. 
To  act  as  controls,  a  similar  system  is  put  up,  in  which 
the  suspected  serum  is  replaced  by  that  from  a  normal 
individual,  and  another  with  serum  from  a  known  syphilitic. 
If  syphilitic  antibodies  are  present  in  the  suspected  serum, 
no  haemolysis  will  take  place,  as  the  complement  required 
by  the  sensitized  red  cells  for  this  reaction  to  occur  have 
been  already  utilized  and  bound  by  the  syphilitic  immune 
body  to  the  lipoid  of  the  liver-extract.  This  constitutes  a 
positive  reaction.  In  the  absence  of  immune  body  from 
the  suspected  serum,  however,  complete  haemolysis  will 
take  place  and  a  negative  reaction  is  recorded. 

By  varying  the  relative  quantities  of  the  reagents 
concerned  in  the  "  syphilitic  system "  the  intensity  of  the 
Wassermann  reaction  is  capable  of  measurement,  and  the 
test  thus  modified  possesses  a  quantitative  as  well  as  a 
qualitative  value — a  point  of  importance  as  a  guide  to  the 
progress  of  treatment. 

To  attain  this  end,  some  observers  dilute  the  serum  and 
test  varying  quantities  of  the  dilution  ;  others  vary  the 
amount  of  antigen  ;  but  the  best  method  entails  the  use  of 
varying  units  of  complement,  thus  estimating  the  number 
of  haemolytic  doses  of  complement  fixed  by  any  given  serum 
in  the  presence  ,of  constant  volumes  of  antigen  and  copula. 

In  reporting  the  results  obtained,  arbitrary  signs  are 
often  employed  :  thus  the  +  sign  indicates  a  positive 
reaction  as  shown  by  total  inhibition  of  haemolysis.  The  — 
sign,  of  course,  indicates  a  negative  reaction,  i.e.  complete 
haemolysis;  whilst  the  combination  +  would  indicate  a 


408       SERUMS,   VACCINES,    AND   TOXINS 

positive  reaction  in  which  a  certain  small  amount  of 
haemolysis  had  taken  place.  Some  observers  record  a  strong 
positive  reaction  as  ++'++>  and  indicate  increasing 
degrees  of  haemolysis  by  +  +  +,  ++,  +,  and  complete 
haemolysis  by  0. 

Various  modifications  of  the  Wassermann  procedure 
have  been  proposed.  Thus,  Forges  and  Meier  x  use  lecithin 
as  antigen  ;  Bauer  2  makes  use  of  the  natural  copula  present 
in  human  blood  instead  of  using  artificial  haemolytic  serum  ; 
Hecht 3  uses  both  the  natural  copula  and  also  the  comple- 
ment of  human  blood,  not  heating  the  patient's  serum ; 
and  Mai'garethe  Stern  uses  the  human  complement  with 
artificial  copula.4  The  details  of  these  modifications  must 
be  studied  in  the  original  papers. 

Wassermann  reaction  in  syphilitic  cases. — Boas r> 

states  that  in  primary  syphilis  the  test  may  be  positive  or 
negative ;  in  any  case  the  reaction  is  not  positive  in  the 
cerebro-spinal  fluid.  In  secondary  syphilis  the  reaction  is 
always  positive  with  serum,  if  the  patient  has  not  been 
treated.  Levaditi  and  Yamanouchi 6  found  that  the  cerebro- 
spinal  fluid  only  yields  positive  results  when  the  nervous 
system  is  involved.  In  tertiary  syphilis  the  reaction 
is  always  positive  in  the  serum,  but  the  cerebro-spinal 
fluid  is  usually  negative.  In  tabes  dorsalis  the  cerebro- 
spinal  fluid  always  gives  the  reaction,  and  this  is  the 
case  in  94  per  cent,  of  cases  of  general  paralysis.  Marcus 7 
gives  the  following  figures :  The  percentage  of  positive 
reactions  in  cases  of  primary  syphilis  is  63,  in  secondary 
syphilis  98,  in  tertiary  syphilis  100,  in  tabes  dorsalis  60, 
in  general  paralysis  100. 

»  Wien.  Min.  Woeh.,  1908,  xxi.  206. 

*  Deut.  med.  Woch.,  1908,  p.  698 ;  Semaine  Mid.,  1908.  p.  429. 

*  Wien.  klin.  Woch.,  1908,  p.  1742  ;  1909,  p.  338. 

«  Zeittchr.f.  Immunitatsforsch.,  1908,  Orig.  I.,  432. 
5  "Die  Wasfiermannsche  Reaktion."     Berlin,  1911. 
8  Compt.  Bend.  Soc.  Biol.,  1907,  Ixii.  240  ;  1908,  Ixiv.  349. 
7  Inaug.  Diss.,  Stockholm,  1910.   Abstr.  in Zeitschi.J.  Immunitatt- 
forsch.,  1910,  p.  1003. 


WASSERMANN'S    REACTION  409 

Plaut1  obtained  a  positive  reaction  in  80  per  cent,  of 
cases  of  undoubted  syphilis. 

Bassett  Smith  2  finds  the  reaction  positive  forty-five  days 
after  infection ;  our  own  observations  lead  us  to  believe 
that  the  reaction  becomes  positive  as  soon  as  spirochsetes 
can  be  demonstrated  in  serum  from  the  primary  lesion. 

Wassermann  reaction  in  other  conditions.— The 

tropical  disease,  yaivs  or  framboesia,  is  so  closely  allied  to 
syphilis  that  many  authorities  have  considered  them  to  be 
identical.  The  causal  spirochsetes  are  practically  indis- 
tinguishable, and  the  symptoms  are  closely  similar ;  only 
the  failure  of  one  condition  to  produce  immunity  to  the 
other  affords  evidence  of  their  diversity.  It  is  therefore 
not  remarkable  that  a  positive  Wassermann  reaction  should 
be  met  with  in  the  subjects  of  yaws.  Another  spirochsetal 
disease,  relapsing  fever,  may  exhibit  the  same  phenomenon, 
as  may  also  ulcus  tropicum  and  malaria.  The  frequency 
of  a  positive  reaction  in  cases  of  leprosy  is  disputed.  The 
only  important  disease  of  temperate  climates  in  which  the 
reaction  is  often  found  positive  is  scarlatina.  A  positive 
test  has  also  been  found  in  patients  who  have  inhaled 
anaesthetics  (Wolfsohn),3  in  cases  of  lead-poisoning  (Field),4 
and  in  one  of  sarcoma,  in  which  last  it  became  negative 
after  the  removal  of  the  tumour  (Lautenschlager).5  We 
have  ourselves  obtained  a  positive  reaction  in  a  case  of  haemo- 
sarcoma  of  the  liver.  It  is  thus  apparent  that  no  serious 
errors  of  diagnosis  are  likely  to  arise  from  positive  reactions 
in  conditions  other  than  syphilis.  Nevertheless  the  non- 
specific nature  of  the  reaction  is  confirmed  by  these  findings. 
The  test  is  unreliable  if  applied  to  serum  taken  after  death. 
Significance  and  variations  of  the  reaction.— 
Apart  from  the  -few  diseases  mentioned  above,  a  definitely 

i  Zentralbl.f.  NervenlieilU.,  1908,  Hft.  8. 
8  Erit.  Med.  Journ.,  1910,  ii.  1434. 

3  Deut.  Med.  Woch.,  1910,  p.  505. 

4  Journ.  Amer.  Med.  Assoc.,  1912,  Ivii.  1681, 

5  Arch.  f.  Laryngol.,  1912. 


410       SERUMS,    VACCINES,    AND    TOXINS 

positive  Wassermann  reaction  points  to  the  presence  of 
active  syphilitic  infection.  A  negative  test  is  not  con- 
clusive against  such  a  condition,  but  renders  its  existence 
improbable  apart  from  convincing  clinical  symptoms.  A 
positive  reaction  in  a  patient's  cerebro-spinal  fluid  points 
to  syphilitic  disease  of  the  central  nervous  system,  either 
of  the  gummatous  variety  or  of  the  late  parasyphilitic 
manifestations,  tabes  dorsalis  and  dementia  paralytica. 

As  a  result  of  treatment  with  mercury  the  Wasser- 
mann reaction  may  become  negative,  but  this  change  does 
not  invariably  occur.  If  after  such  disappearance  the  test 
again  becomes  positive,  it  is  supposed  that  treatment  has 
been  inadequate  and  that  the  infection  persists,  rendering 
danger  of  relapse  imminent.  The  effect  of  treatment  with 
salvarsan  and  neo-salvarsan  is  also  in  many  cases  to  cause 
disappearance  of  the  Wassermann  reaction,  but  here  again 
the  effect  is  not  constant.  Lange l  gives  the  following 
statistics :  Out  of  268  cases,  153  which  were  at  first 
positive  became  negative  after  treatment  with  salvarsan ; 
of  18  which  were  negative,  13  remained  so,  but  5  became 
positive ;  while  93  cases  remained  positive  throughout.  It 
is  certain  that  in  cases  which  have  been  treated  the 
negative  issue  of  the  test  is  of  no  importance  as  an 
indication  that  the  disease  was  not  originally  syphilis. 
Fischer  2  holds  that  the  reaction  affords  no  clear  indication 
either  as  to  prognosis  or  treatment. 

Luetin  reaction. — Noguchi  3  has  devised  a  diagnostic 
test  for  syphilis  analogous  to  the  intradermal  tuberculin 
reaction.  Cultivations  of  many  different  strains  of  Sjjiro- 
chcela  pallida  are  emulsified,  sterilized  by  heating  to 
60°  C.,  and  preserved  by  the  addition  of  0'5  per  cent, 
trikresol  :  O07  c.c.  of  this  preparation,  termed  ''luetin," 
is  injected  into  the  substance  of  the  skin — not  hypo- 
dermically  ;  the  small  wheal  thus  produced  disappears  in 

1  Berl.  klin.  Woc/i.,  19 10,  p.  1656. 

*  Arch.f.  Dermatol.  u.  Syph.,  1910,  c.  215. 

3Jour»,  Exper.  Jfed.,  1911,  xiv.  557. 


SERUMS    IN    SYPHILIS  411 

about  ten  minutes,  and  in  the  positive  reaction  is  replaced 
in  from  twenty-four  to  seventy-two  hours  by  a  skin- 
lesion  ranging  from  a  small  papule  to  a  large  necrotic 
ulcer. 

Serum  therapeutics,1 — Since  the  lower  animals,  with 
the  exception  of  the  ape,  are  immune  to  syphilis  (although 
corneal  and  testicular  lesions  can  be  produced  in  rabbits 
and  guineapigs  by  the  local  inoculation  of  syphilitic 
material  rich  in  spirochsetes),  various  attempts  have  been 
made  to  influence  the  course  of  the  disease  by  injecting 
the  serum  of  animals.  Richet  and  Hericourt  injected  the 
serum  of  dogs  ;  and  other  writers  have  recorded  experiments 
with  serums  of  other  species  (lambs,  Tommasoli ;  horse, 
Kannberg  ;  cattle,  Kollmann).  No  satisfactory  results  have 
been  obtained  by  this  means. 

Injection  of  syphilitic  blood  into  animals,  and  inocula- 
tion with  other  products  of  the  disease  (hydrocele  and  ascitic 
fluid,  chancres),  have  also  been  tried,  the  serum  being  then 
drawn  off,  and  used  therapeutically  (Mazza,  Gilbert  and 
Fournier).  Improvement  is  stated  to  have  ensued  in 
some  of  the  patients  thus  treated.  Risso  and  Cipollina 2 
used  a  serum  derived  from  dogs  and  asses,  in  doses  of 
2-5  c.c.,  and  saw  good  effects  produced  in  all  stages  of  the 
malady. 

Query,3  who  believes  that  the  treponemais  a  stage  in  the 
development  of  a  bacillus  which  he  isolated,  made  use  of 
this  for  immunizing  animals,  and  thence  prepared  a  serum, 
which  Hallopeau  4  believed  to  be  of  value  in  treatment. 

The  serum  of  patients  in  the  tertiary  stage  of  the  disease, 
and  that  of  congenitally  syphilitic  infants,  has  also  been 
employed.  Good  results  are  stated  to  have  been  attained 
in  some  cases  by  this  means  (Gilbert  and  Fournier,  Boeck, 

1  For  the  literature  on  this  subject,  see  Fouquet,  Gaz.  des  Hop., 
Oct.  10,  1903,  p.  1153;  also  Lane,  Practitioner,  July,  1904. 

2  Rif.  Med.,  Nov.  30,  1904;  March  18,  1905. 

3  Oompt.  Send.  Soc.  Biol,  March  9,  1907. 

4  Ibid.,  Dec.  21,  1907. 


412       SERUMS,    VACCINES,    AND    TOXINS 

Moore,  etc.),  but  it  is  evident  that  such  a  mode  of  treatment 
could  never  be  generally  used. 

The  treatment  of  syphilis  has  now,  however,  for  all 
pi'actical  purposes  settled  down  to  the  alternate  exhibition 
of  two  drugs,  salvarsan  and  mercury. 

Chemotherapy.  —  The  term  chemotherapy,  which, 
rightly  speaking,  includes  all  drug-treatment,  is  usually  re- 
stricted to  certain  remedial  measures  that  are  based  upon 
experimental  work,  and  largely  founded  upon  Ehrlich's 
theory  of  receptor  action.  The  difficulty  of  killing  living 
parasites  which  have  gained  entrance  into  the  body 
lies  in  the  fact  that  most  substances  which  are  anti- 
parasitic  are  also  poisonous  to  the  tissues  of  the  host. 
The  great  requisite,  therefore,  of  an  efficient  remedy  is 
that  it  shall  have  the  power  of  attaching  itself  to  the 
parasite  and  killing  it  (parasitotropic),  while  having  no 
affinity  for  the  cells  of  the  body.  Ehrlich  proceeded  on 
the  principle  that,  by  introducing  different  organic  radi- 
cals into  the  substance  containing  such  a  parasiticide  as 
arsenic,  it  might  be  possible  to  find  one  which  would  act 
as  a  copula  capable  of  anchoring  the  arsenic  to  the  parasite, 
while  the  tissues,  having  no  suitable  receptors,  remained 
immune.  The  great  triumph  of  this  method  of  research 
was  the  discovery  of  salvarsan  as  a  remedy  for  syphilis. 

The  systematic  search  for  such  chemical  parasiticides 
was  first  taken  up  in  connection  with  the  form  of  trypano- 
somiasis  which  produces  the  fatal  disease  sleeping-sickness 
or  African  lethargy.  The  use  of  arsenious  acid  with  some 
success  led  to  the  trial  of  other  compounds  of  this  element, 
of  which  atoxyl  (sodium  paramidophenol-arsenate)  and 
arsenophenyl-glycine  were  the  most  valuable.  These 
compounds  were  found  to  be  much  less  toxic  than  arsenious 
acid,  but  in  spite  of  this  many  accidents  occurred  from  their 
use,  especially  affections  of  the  optic  nerve,  which  prevented 
their  employment  from  becoming  general. 

Two  peculiar  features  were  noted  in  connection  with  the 
employment  of  atoxyl :  (1)  that  this  substance  is  not  itself 


CHEMOTHERAPY    OF    SYPHILIS          413 

destructive  of  trypanosomes  in  vitro,  some  vital  activity 
being  apparently  needed  to  develop  its  parasiticidal  pro- 
perties ;  and  (2)  that,  as  a  result  of  its  use,  the  trypano- 
somes in  an  infected  individual  ultimately  become  immune 
to  arsenic,  the  susceptible  parasites  being  apparently  killed 
and  the  survivors  being  able  to  propagate  a  race  refractory 
to  the  poison. 

To  meet  this  second  difficulty,  attempts  were  made  to 
combat  the  disease  with  an  allied  element,  antimony,  and  a 
series  of  compounds  of  this  element,  homologous  with  the 
arsenical  compounds  which  were  found  useful,  was  prepared 
and  tried  with  some  success  ;  alternating  courses  of  arsenic 
and  antimony  were  administered  to  patients  with  consider- 
able benefit,  but  without  any  certainty  of  resulting  cure. 

Some  of  the  antimony  preparations  used  are  enumerated 
by  Uhlenhuthj  Mulzer  and  Hiigel,  viz.  antimonatoxyl  or 
sodium  jD-aminophenyl-antimoniate  ;  sodium  acetyl-/>-amino- 
phenyl  antimoniate,  equivalent  to  arsacetin ;  sodium  ^-ure- 
thane-phenyl-antimoniate,  and  sodium  benzol -sulfon-j9-amino- 
phenyl-antimoiiiate.1  Also,  the  application  of  an  ointment 
containing  "  trixidine  "  (antimony  trioxide),  corresponding 
with  the  use  of  mercurial  inunction,  is  commended  as 
producing  a  "  therapia  mite  (sic)  curans,"  as  opposed  to 
Ehrlich's  unattainable  therapia  magna  sterilisans,  by  Kolle, 
Hartoch,  Rothermundt,  and  Schiirmann.2 

Another  series  of  drugs  used  for  the  purpose  of 
destroying  trypanosomes  in  infected  persons  was  that  of 
benzidine  colours — trypan-red,  trypan-blue,  and  so  forth  ; 3 
while  yet  another  was  formed  of  compounds  of  trimethyl- 
amine — malachite  green,  parafuchsine,  and  tryparosan.  The 
results  were  not  very  satisfactory. 

1  Deut.  med.  Woch.,  1913,  p.  393.     See  also  Plimmer  and  Thom- 
son, Proa.  Roy.  Soc.,  1908,  Ixxx.  1 ;  Mesnil  and  Brimont,  Bull.  Soc. 
Path.  JSxot.,  1908,  i.  44,  210. 

2  Ibid.,  1913,  p.  825. 

3  Ehrlich  and  Shiga,  Berl.  klin.  Woeh.,  1904,  March  28  and  April 
11  ;  Nicolle  and  Mesnil,  Ann.  Inst.  Pasteur,  190(5,  xx.  417,  513. 


414       SERUMS,   VACCINES,    AND   TOXINS 

The  most  conspicuous  research  directed  to  finding  a 
chemical  parasiticide  was  that  carried  out  by  Ehrlich  and 
his  coadjutors  with  a  view  to  discover  an  arsenical  anti- 
dote to  syphilis.  An  immense  number  of  compounds  were 
investigated,  the  most  successful  being  the  606th  of  the 
series,  subsequently  known  as  "  606  "  or  salvarsan.  This 
is  chemically  dioxy-diamido-arseno- benzol,  of  which  the 
graphic  formula  is  shown  below  : 

As    =====    As 

A  /\ 


NH, 

OH  OH 

Dioxy-diamido-arseno-benzol  =  "COG." 

METHOD  OF  ADMINISTERING  SALVARSAX 
Salvarsan  was  originally  injected  intramuscularly  in  an 
oily  suspension.  It  was  soon  found,  however,  that  the 
intravenous  injection  of  a  neutral  saline  solution  gave 
better  results  in  a  shorter  space  of  time,  and  this  method 
is  now  universally  adopted.  It  is,  however,  frequently 
followed  during  the  ensuing  six  hours  by  certain  un- 
welcome general  symptoms,  such  as  pyrexia  (often  up 
to  104°  F.),  rigors,  nausea,  vomiting,  and  diarrhoea,  the 
majority  of  which  can  be  avoided  if  due  attention  is 
paid  to  certain  points  in  technique,  such  as  the  use  of 
bacteria-free  sterile  distilled  water  for  the  preparation 
of  the  solution  of  the  drug  and  for  the  saline  diluent, 
and  careful  preparation  of  the  patient.  It  should  be 
noted  that  in  patients  who  are  the  subjects  of  primary 
and  early  secondary  lesions  the  injection  of  salvarsan  is 
followed  by  a  sharp  rise  of  temperature  dui-ing  the  four 
to  six  hours  immediately  following  the  injection,  said  to  be 
due  to  the  liberation  of  endotoxin  from  the  bodies  of  the 
spirochsetes  which  have  been  destroyed  by  the  drug.  This 
pyrexia  is  variable  in  extent  and  is  unavoidable.  The 


SALVARSAN  415 

appearance  of  a  rash,  or  the  extension  of  an  already  existent 
rash,  may  also  occur  a  few  hours  after  the  injection  and 
persist  for  several  days — a  phenomenon  known  as  the 
Herxheimer  reaction,  and  attributed  to  the  same  cause, 
or  alternatively  to  stimulation  of  the  growth  of  spirochsetes 
by  a  dose  which  is  insufficient  to  cause  their  death. 
According  to  Rolleston,1  the  injection  causes  a  fall  of 
blood-pressure ;  and  on  rare  occasions  symptoms  of  syncope, 
cyanosis,  imperceptible  pulse,  and  cessation  of  breathing 
immediately  follow  the  administration  of  the  drug.  In 
such  cases  the  subcutaneous  injection  of  adrenalin  must  be 
resorted  to.  The  bulk  of  the  arsenic  is  excreted  by  the 
kidneys  within  twenty-four  hours,  and  usually  the  elimin- 
ation is  completed  within  a  week ;  but  occasionally  it  is 
delayed,  therefore  a  second  injection  should  not  be  given 
until  all  traces  of  the  drug  have  disappeared.  Several  deaths 
from  acute  arsenical  poisoning  have  been  recorded  through 
neglect  of  this  point. 

Local  symptoms,  if  the  injection  is  skilfully  carried 
out,  should  be  entirely  absent. 

Before  injection. — The  patient  should  be  prepared 
for  the  intravenous  injection  as  for  a  major  operation.  A 
sharp  purge  administered  overnight  should  be  followed  in 
the  morning,  if  necessary,  by  an  enema.  Breakfast  should 
consist  of  a  cup  of  beef-tea  and  a  piece  of  dry  toast  only. 
No  further  food  should  be  administered  before  the  opera- 
tion. The  patient  should  remain  in  bed,  and  the  injection 
be  given  about  midday. 

The  general  procedure  is  as  follows : — 

(«)  Distilled  water  and  normal  saline  solution  must  be  freshly 
prepared,  sterilized,  and  brought  to  a  temperature  of  40°  C. 

(b)  Open  the  phial  of  salvarsan  (by  filing  the  neck  with  the  file 
supplied  in  the  packet,  and  snapping  off  the  neck),  and  empty 
its  contents  into  a  sterilized  dry  flask  containing  sterile  glass 
beads.  Shake  for  a  few  seconds  in  order  to  break  up  any 
lumps  of  the  drug. 

1  Brit  Med.  Journ.',  1915,  ii.  281. 


416       SERUMS.,    VACCINES,    AND   TOXINS 

(e)  Measure  out  30  c.c.  of  hot  sterile  distilled  water  and  pour 
into  the  flask.  Shake  gently  and  evenly  until  the  whole  of  the 
salvarsan  is  dissolved.  An  acid  solution  of  salvarsan  has  now 
been  prepared  containing1  0'6  grm.  in  30  c.c..  or  0-1  grm.  in 
every  5  c.c.  (the  usual  dose  for  a  small  infant  is  0'2  grm.,  for 
a  child  or  feeble  woman  0-4  grm.,  for  a  robust  woman 
0-5  grm.,  and  for  a  man  0P6  grm.).  If  therefore  it  is  decided 
to  give  a  dose  of  less  than  0-6  grm..  the  surplus  solution 
should  be  removed  from  the  flask  by  means  of  a  sterilized 
measuring  pipette  and  discarded. 

(d)  Add  to  the  acid  solution  of  salvarsan  sufficient  of  the  normal 
saline  solution  to  make  the  bulk  of  the  fluid  up  to  100  c.c. 

(e)  Neutralize    the    acid   solution    by    the   addition   of  normal 

caustic  soda,  of  which  0-7  c.c.  should  neutralize  each  O'l  grm. 
of  salvarsan  ;  usually  rather  more  is  required.  Assuming  the 
dose  given  to  be  0'6,  then  4  c.c.  of  soda  solution  should  be 
added,  and  will  result  in  the  formation  of  a  copious  yellow 
precipitate,  which  on  the  flask  being  gently  shaken  will 
again  go  into  solution.  If  the  colour  of  the  fluid  is  dull, 
or  all  the  precipitate  has  not  been  taken  up,  add  soda  solu- 
tion drop  by  drop,  shaking  the  flask  gently  the  while,  until 
the  desired  result  is  obtained.  Only  solutions  sherry-bright 
in  colour  and  perfectly  free  from  flocculi  should  be  injected. 
(/)  Now  make  up  the  bulk  of  the  solution  to  about  200-250  c.c. 
by  the  further  addition  of  warm  normal  saline  solution. 

At  the  time  Of  injection. — The  strictest  attention 
should  be  devoted  to  asepsis.  The  operation  is  carried 
out  in  the  main  as  described  under  Intravenous  Injection 
(p.  51).  The  fluid  may  be  introduced  with  the  help  of 
a  special  syringe  provided  with  a  two-way  tap,  permitting 
the  barrel  to  be  refilled  without  removing  the  needle  from 
the  vein ;  preferably  the  needle  used  for  the  venipuncture 
is  attached  by  a  length  of  rubber  tubing  to  a  burette  con- 
taining the  salvai'san  solution,  and  the  injection  made  by 
gravity. 

After  injection. — The  limb  which  has  been  operated 
upon — usually  an  arm — should  be  raised  on  a  pillow  and 
lightly  covered  with  cotton-wool  or  a  wi-ap  to  keep  it  warm. 
The  pillow  should  be  removed  from  under  the  patient's 
head.  The  patient  should  remain  as  still  as  possible  for 


SALVARSAN  417 

the  next  twenty-four  hours,  and  in  no  case  rise  or  get  out  of 
bed.  Whenever  necessary  the  bed-pan  must  be  used. 

No  solid  food  should  be  given  during  the  twenty- 
four  hours  following  the  injection ;  milk  and  soda,  beef- 
tea,  Benger's  food  or  similar  preparations  may  be  given. 
Twenty-four  hours  later,  if  no  untowai-d  symptoms  have 
occurred,  the  patient  may  move  in  bed,  sit  up,  have  light 
food,  fish,  chicken,  etc.,  and  forty- eight  hours  after  the  in- 
jection may  go  on  to  full  diet  and  resume  his  ordinary 
avocation. 

Neo-salvarsan. — -Still  further  investigation  conducted 
up  to  the  914th  compound  led  to  the  discovery  of  a  com- 
pound of  salvarsan  with  sodium-formaldehyde-sulphoxylate 
(CH.,[OH].P.SO.Na),  to  which  the  name  neo-salvarsan  has 
been  applied,  and  which  is  more  easily  administered  and 
less  liable  to  be  followed  by  disagreeable  effects,  although 
not  quite  so  effective. 

The  dose  of  neo-salvarsan  up  to  0-9  grm.,  which  corre- 
sponds to  0*6  grm.  salvarsan,  should  be  dissolved  in  10  c.c.  of 
sterile  distilled  water  or  sterile  normal  saline  solution,  and 
slowly  injected  into  a  vein  by  means  of  an  all-glass  syringe. 
The  concentration  of  the  drug  does  not  appear  to  be  of 
importance  ;  we  have  injected  O9  grin,  dissolved  in  2  c.c.  of 
water,  intravenously,  with  good  results. 

BRITISH  AND  FRENCH  EQUIVALENTS  OF  SALVARSAN 

Salvarsan  was  marketed  in  England  by  the  firm  of 
Meister  Lucius  &  Briining,  and  with  the  outbreak  of  the 
present  European  War  the  supply  of  German-controlled 
"  606  "  ceased. 

The  French,  however,  have  manufactured  an  identical 
product  from  the^ime  Ehrlich  published  his  experiments, 
the  chief  supply  being  derived  from  the  house  of  Messrs. 
Poulonc  Freres  under  the  name  of  arseno-benzol  or 

arsenobillon.  Novo-arseno-benzol,  corresponding  to 
neo-salvarsan.  was  also  made  by  the  same  firm.  The 
directions  for  using  these  preparations  are  identical  with 


418       SERUMS,    VACCINES,    AND    TOXINS 

those  already  given  for  the  use  of  salvarsan  and  neo- 
salvarsan. 

Recently,  the  Board  of  Trade  has  granted  a  licence  to 
Messrs.  Burroughs  Wellcome  &  Co.  to  prepare  the  drug 
under  the  name  of  kharsivan.  This  is  now  on  the 
market  and,  save  that  it  is  not  so  readily  dissolved,  is 
identical  with  the  original  salvarsan. 

Another  substitute  for  salvarsan  is  known  as  galyl. 
It  is  a  derivative  of  arseno-benzol,  two  molecules  of  which 
are  linked  with  two  phosphoric  groups  to  form  tetraoxy- 
diphospho-amino-diarseno-benzene.  It  is  sent  out  for  intra- 
venous injection  as  a  yellow  powder,  in  hermetically  sealed 
glass  ampoules,  accompanied  by  a  tube  of  sodium  carbonate 
solution  sufficient  when  used  for  the  dilution  of  galyl  to 
form  an  isotouic  solution,  which  must  be  prepared  im- 
mediately before  use.  Three  injections  are  recommended  at 
weekly  intervals  in  doses  of  0-25,  0-30,  0-35  or  040  grm. 
Excellent  results  have  been  obtained  in  the  treatment  of 
syphilis  with  this  drug  by  Abraham,1  Foerster  2  and  Spence.3 

Intramine,  a  sulphur  di-ortho-body  synthesized  by 
McDonagh,4  has  not  yet  had  a  sufficiently  extended  clinical 
trial  to  permit  of  judgment  being  passed  upon  its  value. 

Salvarsan   in    diseases    other    than    syphilis.— 

Salvarsan  has  been  tried,  and  good  effects  attributed  to  it, 
in  numerous  other  affections  besides  syphilis.  In  yaws 
(frarnbcesia  tropica),  a  single  injection  is  said  to  bring  about 
lasting  cure  (Castellani,5  Host,6  Sabella  7).  In  spirochsetal 
affections  of  the  mouth  it  has  been  recommended  by  Gerber,8 

1  Brit.  Med.  Journ.,  1914,  i.  582. 

2  Lancet,  l',»15,  ii.  645. 
a  Ibid.,  1915,  ii.  1292. 
4  Ibid.,  1916,  i.  236. 

6  Arch.f.  Scliiffs.u.  Tropenhyg.,  1911,  xv.  11. 

6  Munch.  med.'Woch.,  1912,  p.  924. 

7  IlPolitlin.,  Sez.  Prat.,  Aug.,  1912. 

8  Munch,  med.  Wocli.,  Feb.  28,  1911. 


SALVARSAN  419 

and  as  a  local  application  by  Zilz,1  and  in  the  probably 
spirochsetal  diseases,  tropical  ulcer  and  ulcerative  graiiu- 
loma  of  the  pudenda,  by  Rodenwaldt,2  Kiilz  3  (locally),  and 
Sabella.  *  In  malaria  it  is  said  to  be  effective  in  tertian  but 
not  in  quartan  or  malignant  cases  (Tversen  and  Tuschinski)."' 
Bramwell0  has  recorded  two  cases  of  pernicious  anaemia 
treated  with  salvarsan ;  and  we  have  ourselves  employed 
the  drug  with  benefit  in  several  cases  of  pernicious  and 
other  forms  of  antemia.  Still  other  conditions  in  which 
this  remedy  has  been  tried  are  pellagra  (Nice,  MacLester, 
and  Torrance,7  Cole  and  Winthrop8),  lichen  ruber  planus 
(Herxheinier),y  rabies  (Tonin),10  small-pox  (Sunder),11  chorea 
(Szametz),12  amrebic  dysentery  (Matsuura),13  Oriental  sore 
(Peterson),1*  and  sarcoma  (Czerny  and  Cann).15 

Noguchi  has  now  shown  conclusively  that  general 
paralysis  of  the  insane  is  a  late  manifestation  of  the  activity 
of  the  Treponema  pallidum,  and  consequently  treatment 
of  the  disease  has  once  more  resolved  itself  into  the  use  of 
active  antisyphilitic  remedies,  chiefly  on  the  lines  of  (1) 
intrathecal  injection  of  salvarsanized  serum  (Marmisco,16 
Ford  Robertson, "Purves  Stewart,18  Swift  and  Ellis19),  and 

1  Munch,  med.   Woch.,  1912,  p.  20. 

2  Arch,  f.  Schiffs.  u.  Tropenhyg.,  1912,  xvi.  562. 

3  Ibid.,  p.  563. 

4  II  Polldin.,  Sez.  Med.,  1912. 

5  Dent.  med.  Woch.,  1911,  No.  3. 

6  Brit.  Med.  Journ.,  1911,  i,  547. 

7  Journ.  A'nier.  Med.  Assuc.,  March  25,  1911. 

8  Ibid.,  June  17,  1911. 

9  Dcut.  med.  Woch.,  1910,  No.  33. 

10  II  Policlin.,  July  14,  1«J12. 

11  Areh.f.  Schiffs.  u.  Tropenhyg.,  1912,  xvii.  563. 
1-2  Munch,  med.  Woch.,  1912,  p.  2333. 

13  Abstr.  ia  Zeits.f.  Immunitatsforsch.,  1911,  p.  1020. 

14  Munch,  med.  Wcch.,  1912,  p.  2491. 

15  Ibid.,  April  25,  1911. 

16  Presse  Med.,  Jan.  28,  1911. 

!7  Edin.  Med.  Journ.,  1913,  pp.  293  and  428. 

18  Brit.  Med.  Journ.,  1914,  i.  949. 

19  Munch,  med.  Woch.,  Sept.  9,  1913. 


420       SERUMS,    VACCINES,    AND   TOXINS 

(2)  the  direct  injection  of  a  small  quantity  of  6  per  cent, 
solution  of  neo-salvarsan  (Ravaut)  i  into  the  spinal  canal 
immediately  before  the  injection  of  0*45  grin,  of  the  drug 
intravenously. 

The  technique  of  the  former  method  is  as  follows : 
Administer  an  intravenous  injection  of  O3  grm.  salvarsan 
or  0'45  grm.  neo-salvarsan  ;  one  or  two  hours  later  with- 
draw 40  to  60  c.c.  blood  by  venipuncture,  and  allow 
it  to  clot.  Separate  off  the  serum,  dilute  it  Avith  normal 
saline  to  form  a  40  per  cent,  solution,  and  place  for  one  hour 
in  a  water-bath  at  56°  C.  Twenty -four  hours  later  perform 
lumbar  puncture  (see  p.  54)  upon  the  patient,  and  withdraw 
10  to  20  c.c.  of  cerebro-spinal  fluid.  Then  run  in,  by  gravity, 
30  to  35  c.c.  of  the  diluted  serum,  and  elevate  the  foot  of 
the  bed  to  favour  diffusion  of  the  serum  upwards  to  the 
cranial  cavity.  Repeat  the  entire  process  at  intervals  of 
seven  to  fourteen  days. 

RELAPSING   FEVER 

Etiology. — The  causal  agent  of  relapsing  fever  was 
discovered  by  Obermeier,  and  is  named  after  him  the 
Spirochceta  (spirillum)  obermeieri. 

Agglutination    and    bacteriolysis.  —  Sawtschenko 

and  Melkich  2  found  that  the  serum  of  convalescing  patients 
had  an  agglutinative  power  on  the  organisms,  and  that  it 
also  contained  a  copula  which  was  capable  of  producing 
destruction  of  the  organisms  within  the  leucocytes.  They 
held  that  the  action  of  this  body  was  to  transform  the 
negative  chemiotactic  effect  of  the  spirochtetes  upon  the 
leucocytes  into  positive  chemiotaxis  (i.e.  opsonizing).  There 
was  no  free  complement  in  the  blood-plasma,  so  that  no 
bacteriolysis  took  place  outside  the  cells.  Heating  the  serum 

1  Ann.  de  Med.,  1914,  p.  51. 

2  Ann.  dc  Vlnst.  Pasteur,  1901,  xv.  207.     The  bactericidal  power 
of  the  blood  of  the  convalescents  was  first  shown  by  Gabritschewsky, 
Ann.  de  I'Tnat.  Pasteur,  1896. 


RELAPSING   FEVER  421 

led   to  loss  of  its  bacteriolytic  property,  but  not  of   its 
agglutinins. 

Hodlmoser1  finds  the  serum  of  convalescents  to  be 
lytic  rather  than  agglutinative. 

Serum  treatment. — Lowenthal 2  has  produced  a  bac- 
tericidal serum  by  inoculation  of  horses  with  the  spirilla, 
and  good  results  are  claimed  as  the  result  of  its  use. 

Dobrosrakow  3  also  immunized  horses  with  the  defibrin- 
ated  blood  of  patients  suffering  from  relapsing  fever,  and 
used  their  serum  for  treatment,  with  apparent  benefit. 

Chemotherapy. — Buth  4  has  treated  cases  of  relapsing 
fever  with  salvarsan,  with  apparently  good  results. 

1  Zeitsehr.f.  Hellk.,  xxvi.,  Heft  11. 

2  Deut.  med.  Wocli.t  1898. 

3  Abstr.  in  Centralbl.  f.  inn.  Med.,  1907,  p.  1039. 

4  Berl.  Jclin.  Wooh.,  1913,  p.  1231. 


CHAPTER   XXII 

MALIGNANT   TUMOURS 
Etiology  of  malignant    growths. — Nothing   certain 

is  known  as  to  the  causation  of  malignant  tumours.  The 
hypothesis  that  they  are  produced  by  the  action  of  parasitic 
organisms  appears  to  lack  any  satisfactory  evidence  and 
is  insufficient  to  account  for  many  of  the  peculiarities 
of  new  growths.  Sanfelice  1  produced  some  evidence  in 
favour  of  the  blastomycetic  origin  of  malignant  neoplasms, 
claiming  to  have  produced  both  carcinoma  and  sarcoma 
experimentally  by  the  injection  of  toxins  of  such  micro- 
organisms, and  to  have  cured  these  experimental  tumours 
by  the  administration  of  an  antitoxic  serum  prepared  by 
immunizing  other  animals  by  the  injection  of  attenuated 
toxins.  But  hitherto  no  generally  accepted  organism  or 
toxin  has  been  isolated  with  which  an  antitoxic  or  germi- 
cidal  serum  could  be  prepared.  Treatment  has,  how- 
ever, been  tried  on  several  different  lines.  On  the  sup- 
position that  a  parasite  is  present  in  tumours,  although 
it  has  not  been  discovered,  some  observers  have  tried 
injecting  animals  with  portions  of  cancerous  or  other 
tumours,  and  applying  the  serum  obtained  from  them 
to  the  cure  of  the  disease.  Reference  has  already  been 
made  in  the  introductory  chapters  of  this  work  to  the 
attempt  to  obtain,  by  injection  of  cancer-cells  into  animals, 
a  cytolytic  serum  which  shall  be  specific  for  these  tumours  : 
the  practical  results  of  this  mode  of  treatment  do  not 
appear  to  have  been  very  encouraging.  The  most  hopeful 
line  of  treatment  on  bacterial  lines  is  that  inaugurated  by 

1  Brit.  Med.  Assoc.  meeting,  Belfast,  1909. 
422 


MALIGNANT    TUMOURS  423 

Coley,  who  employs  the  toxins  of  certain  bacteria  which 
seem  to  have  a  power  of  producing  degeneration  in  the  cells 
of  tumours  ;  but  it  need  hardly  be  pointed  out  that  this 
mode  of  treatment  is  quite  different  from  serum  treat- 
ment, or  even  from  vaccines  or  toxins  as  applied  to  other 
diseases  in  which  the  specific  organism  is  known. 

Diagnosis. — Numerous  serological  methods  for  the 
diagnosis  of  malignant  growths  have  also  been  proposed  ; 
thus  the  complement-fixation  test  has  been  employed,  an 
alcoholic  extract  of  tumour-tissue  serving  as  antigen  (von 
Dungern),1  and  the  antitryptic  value  of  the  serum  has 
been  estimated,  an  increase  in  this  content  being  held 
to  point  to  the  existence  of  a  tumour.3  Piorkowski3  states 
that  a  ring  of  precipitate  is  formed  when  a  solution  of 
saponified  cancer-tissue  is  brought  into  contact  with  the 
serum  of  a  patient  suffering  from  the  disease.  Freund  and 
Kaminer  *  report  that  normal  human  serum  dissolves  cancer- 
cells,  but  that  the  serum  of  a  cancer-patient  does  not  do  so. 
The  meiostagmin  reaction  (p.  92)  has  also  been  used  for 
the  diagnosis  of  malignant  disease. 

A  special  cutaneous  reaction  (hsemolytic  skin-reaction) 
has  been  described  by  Elsberg,5  which  consists  in  injecting 
intracutaneously  5  minims  of  a  20  per  cent,  suspension  of 
normal  blood-coi-puscle  in  saline  fluid.  If  the  patient  is  the 
subject  of  cancer,  a  swollen  area  appears  within  three  to 
twelve  hours,  and  undergoes  changes  of  colour  from  brown 
to  greenish-yellow.  In  a  normal  person  no  such  result 
occurs.  Elsberg,  Neuhof  and  Geist6  found  the  reaction 
present  in  62  per  cent,  of  patients  who  were  the  subjects  of 
malignant  disease,  and  only  in  15  per  cent,  of  non-can- 
cerous persons.  Advanced  cases  with  multiple  metastases 

i  Miinch.  med.  Woc/t.,  1912,  p.  05. 

-  Miiller  and  Jochmann,  Vcrhandl.  Kongr.  inn.  med.  Wiexb.,  1907. 
»  Berl.klin.  Woch.,  1914,  No.  6. 

*  Wien.  Min.  Woch.,  1910,  No.  34. 

5  Jonrn.  Amcr.  Med.  Assoc,,  March  27,  1909. 

6  Amer.  Journ.  Med.  Sci.,  Feb.,  1910. 


424       SERUMS,    VACCINES,    AND    TOXINS 

are,  however,  invariably  negative.  Risley,1  on  the  other 
hand,  finds  the  numbers  only  33^  per  cent,  in  cancerous 
subjects,  and  20  per  cent,  in  normal  individuals ;  hence  the 
test  seems  of  little  value. 

COLBY'S  FLUID 

Principle  of  treatment. — It  was  observed  many  years 
ago  that  an  attack  of  erysipelas  occurring  spontaneously 
in  a  patient  suffering  from  malignant  disease  sometimes  had 
the  effect  of  causing  a  disappearance  or  retrogression  of  the 
growth.  Attempts  were  therefore  made  to  treat  cases  of 
cancer  by  artificial  production  of  erysipelas,  by  inoculation 
with  the  streptococci.  Some  very  successful  results  were 
obtained  by  Fehleisen  both  in  sarcoma  and  carcinoma,  and 
Coley  and  others  also  reported  cases  apparently  cured  by 
this  means.  Some  fatal  cases,  however,  occurred  from  this 
treatment,  and  it  was  abandoned  as  too  dangerous.  Coley  ~ 
subsequently  proposed  to  produce  the  same  effect,  but  in  a 
manner  more  under  control,  by  means  of  injections  of  the 
toxins  formed  by  the  cocci  in  artificial  media. 

Preparation  Of  the  fluid. — Coley  at  tirst  obtained 
the  toxins  by  growing  together,  in  flasks  of  broth,  cultures 
of  the  Streptococcus  eryslpelatosus  (Streptococcus  pyogenes) 
and  of  the  Bacillus  prodigiosus,  sterilizing  by  heating  to 
58°  C.,  and  using  the  unfiltered  fluid,  containing  the  dead 
bodies  of  the  organisms,  for  injection.  For  weakly  patients 
and  children  Coley  advised  the  use  of  the  filtered  culture, 
as  being  less  toxic  (in  the  proportion  of  1  :  10). 

Now,  however,  the  fluid  is  prepared  in  a  different 
manner.3  The  streptococcus  is  grown  in  broth  for  three 
weeks.  To  every  100  c.c.  of  the  culture  are  added  30  c.c.  of 
an  emulsion  of  B.  prodigiosus  (standardized  by  Kjeldahl's 
method  to  contain  12-5  mg.  of  protein  per  c.c.)  and  20  c.c. 

1  Boston  Med.  and  Surg.  Journ.,  1911,  ii.  127. 

2  Art.  "Erysipelas,  Curative,"  in  Quain's  "Dictionary  of  Medi- 
cine," 3rd  ed.,  1902,  p.  486. 

3  Proc.  Roy.  Soc.  Med.,  Surgical  Sect.,  1909,  July  13. 


COLBY'S    FLUID  425 

glycerin.  A  piece  of  thymol  is  added  to  the  mixture,  and 
the  whole  is  sterilized  by  heating  to  75°  C.  for  two  hours. 
Virulent  strains  of  the  streptococci  are  used  for  making  the 
cultures,  their  vigour  being  maintained  by  passage  through 
rabbits. 

Dose  Of  the  fluid. — The  initial  dose  advised  by  Coley 
is  i  to  i  minim,  injected  into  the  buttock  with  all  anti- 
septic precautions  ;  if  injected  into  the  substance  of  the 
tumour,  the  dose  should  not  be  more  than  yL  minim.  The 
injections  may  be  repeated  every  two  or  three  days.  A 
temperature  reaction  of  about  102°-104°  F.  should  be 
aimed  at,  and,  so  long  as  this  is  obtained,  no  increase  in 
the  dose  should  be  made.  When  necessary,  the  increment 
should  be  i  minim.  The  biggest  dose  is  usually  8  minims, 
though  20  minims  have  been  given.  If  no  good  results  are 
observed  within  the  first  three  or  four  weeks,  it  may  be 
concluded  that  the  case  is  not  suitable  for  the  treatment. 
If,  however,  any  diminution  in  the  size  of  the  growth  is 
seen,  the  injections  may  be  continued  over  long  periods  of 
time,  until  the  tumour  has  entirely  disappeared.  Even  then 
the  injections  should  be  continued  in  smaller  doses  at  longer 
intervals  for  another  four  months.  Occasional  intermissions 
in  the  course  of  treatment  are  advisable. 

Results  Of  injections. — Coley  l  reported  a  total  of 
230  cases  in  which  his  treatment  had  been  adopted,  and 
among  these  2  died  as  a  result  of  the  injections — one  from 
accidental  sepsis  (staphylococcic),  the  other  from  embolism 
due  to  too  large  an  initial  dose.  Thirteen  patients  had 
passed  the  three-year  limit,  generally  considered  to  author- 
ize the  claim  of  "  cure."  More  recently  2  he  has  reported 
a  further  series  of  cases,  making  the  total  up  to  500,  and 
including  one  more  death  from  embolism.  It  also  includes 
52  inoperable  cases  which  were  successfully  treated,  and  of 
these  35  remained  well  after  from  three  to  sixteen  years. 
Recurrences  took  place  in  3  cases  which  had  shown 

1  Journ.  Amer.  Med.  Assoc.,  1900,  i.  906. 

2  Op.  supra  cit. 


426       SERUMS,    VACCINES,    AND    TOXTNS 

definite  improvement,  thus  attesting  the  correctness  of  the 
diagnosis.  Coley  also  records  35  cases  treated  by  other 
surgeons,  with  the  result  that  in  26  the  tumours  disappeared, 
and  14  patients  were  alive  from  two  to  four  years  afterwards. 

In  other  hands  the  treatment  has  not  always  proved 
so  successful  as  would  appear  from  Coley's  results,  but  it 
may  be  pointed  out  that  many  of  the  failures  date  from 
fifteen  years  ago. 

The  cases  best  adapted  for  this  toxin  treatment  would 
seem  to  be  the  spindle-celled  sarcomas,  which  are  those  least 
malignant  in  type  and  most  nearly  approaching  organized 
tissue  in  their  structure.  Coley 1  collected  430  cases  of 
sarcoma  treated  by  this  fluid  :  the  tumours  entirely  disap- 
peared in  47  (11  per  cent.),  and  28  of  these  cases  were  alive 
and  well  after  from  three  to  fifteen  years.  Melanotic 
sarcoma  does  not  seem  amenable  to  the  injections.  Coley 
does  not  recommend  his  treatment  in  cases  in  which  opera- 
tive removal  of  the  growth  is  possible.  In  cases  which  are 
inoperable  it  appears  well  worthy  of  trial. 

Coley  explains  the  good  effects  seen  after  injection  of 
toxins  as  being  due  to  the  induction  of  an  environment 
unsuitable  to  the  life  of  the  cancer-cell,  which  degenerates  in 
consequence.  He  holds  that  malignant  tumours  are  pro- 
duced by  a  parasitic  organism  which  is  affected  by  this 
treatment,  just  as  cases  of  tuberculosis  and  of  syphilis  have 
been  observed  to  show  improvement  after  attacks  of 
erysipelas.  It  does  not  appear  necessary  to  see  in  Coley's 
results  a  support  to  the  parasitic  hypothesis.  It  is  well 
known  that  the  cells  of  tumours  are  of  low  vitality ;  and 
it  is  quite  conceivable  that  they  may  succumb  to  the  action 
of  poisons  circulating  in  the  blood,  when  more  resistant 
cells,  such  as  those  of  normal  tissues,  are  unaffected.  It  is 
also  possible  that  the  effect  of  the  toxins  is  to  supply  in 
some  way  a  stimulant  to  the  normal  connective  tissue, 
and  that  its  cells  are  enabled  to  offer  a  more  vigorous  resist- 
ance to  the  invasion  of  the  tumour  »s  the  result  of  this 
1  Boston  Ned.  and  Surg.  Journ.,  1908,  clviii.  17J. 


SERUM  TREATMENT  OF  TUMOURS       427 

stimulus.  In  tuberculosis  and  syphilis  the  action  of 
erysipelas  must  be  exerted  in  the  direction  of  an  increase 
of  tissue-reaction  or  possibly  of  phagocytosis,  since  it  can 
hardly  be  maintained  that  the  toxins  of  streptococci  have 
a  specific  action  on  other  organisms.  The  effect  of  bacterial 
toxins  in  inducing  granular  and  fatty  degeneration  of 
tissues  is  well  recognized,  and  the  proneness  of  the  cells  of 
tumours  to  undergo  these  changes  is  noteworthy.  That  a 
conflict  takes  place  between  the  healthy  cells  of  the  body 
and  the  invading  cells  of  a  tumour  seems  evident,  not  only 
on  theoretical  grounds,  but  on  account  of  the  signs  of  irrita- 
tion and  reaction  seen  at  the  periphery  of  a  malignant 
growth.  It  is  not  impossible  that  both  of  the  factors  sug- 
gested may  play  a  part  in  the  action  exerted  by  the  toxins 
of  erysipelas  on  tumours.  It  is  noteworthy  that  the  most 
marked  effect  is  produced  on  the  sarcomas,  which  are 
connective-tissue  tumours,  and  that  the  reaction  which  is 
called  "inflammation,"  and  which  is  induced  by  the  action 
of  bacterial  toxins,  is  also  seen  in  connective  tissue. 

SERUM   TREATMENT 

Emmerich  and  Scholl's  serum. — An  attempt  on 
rather  different  lines  to  utilize  erysipelas  as  a  cure  for  tumours 
was  made  by  Emmerich  and  Scholl,1  who  inoculated  sheep 
with  the  cocci  of  erysipelas,  and  used  the  serum  of  these 
animals  for  treatment  of  patients.  Improvement  seemed  to 
result  in  some  cases,  but  not  actual  cure.  Reineboth  2  records 
a  case  in  which  this  serum  was  used,  and  in  which  the 
growth  showed  signs  of  softening  as  a  result  of  the  injec- 
tions ;  but  the  patient  died  in  spite  of  the  treatment. 

WlaefTs  serum. — Wlaeff  and  D'Hotman  de  Villiers  3 
obtained  cultures1  of  blastomycetes  from  cancerous  growths, 
and  with  them  inoculated  pigeons.  They  then  took  the 
serum  of  these  birds  and  tried  it  on  rats  as  a  protective 

1  Deut.  med.  Woch.,  1895,  No.  17. 

2  Ibid.,  1895,  No.  48. 

3  Compt.  Rend,  de  la  Soc.  de  Biologle,  1900,  p.  611. 


428       SERUMS,    VACCINES,    AND    TOXINS 

against  the  form  of  cancer  from  which  these  rodents  suffer. 
This  serum  has  been  used  as  a  remedy  for  human  cancer. 
Wlaeff  reports  that  it  causes  the  leucocytes  to  surround, 
penetrate,  and  destroy  isolated  epithelial  cells.  Reynier  l 
reports  that  its  use  relieves  pain  and  produces  general 
improvement  in  patients,  but  that  the  growth  of  the  tumours 
is  not  checked.  Other  cases  with  very  similar  results  are 
recorded  by  Berger  ~  and  Richelot.3  Lucas-Championniere  * 
did  not  find  that  any  benefit  was  derived  from  the  injections 
in  cases  in  which  he  tried  it. 

The  idea  that  blastomycetes  are  the  causal  agents  in 
cancer  is  not  maintained  by  many  authorities  at  the  present 
day,  and  it  is  difficult  to  believe  that  any  real  effect  can  be 
produced  in  human  cancer  by  such  a  serum  as  that  just 
described.  It  is  possible  that  a  certain  degree  of  irritation 
might  be  caused  by  foreign  serum  injected  into  a  human 
being,  and  that  some  temporary  effect  might  be  induced  in 
a  tumour  into  which  it  was  injected.  Probably  the  only 
good  results  were  owing  to  suggestion  ;  the  patient  was 
led  to  believe  that  some  good  would  be  done,  and  either 
imagined  this  or  attributed  some  incidental  improvement 
to  the  serum. 

Doyen's    antitoxic    serum. — Doyen5    has  isolated 

from  malignant  growths  an  organism  to  which  he  gives 
the  name  of  Micrococcus  neoformans,  and  has  prepared 
an  antagonistic  serum  by  injection  of  its  toxins  into 
animals.  This  serum  he  has  employed  for  the  treatment 
of  cancer,  injections  being  made  into  the  buttocks.  Of  a 
total  of  126  cases,  58  showed  no  improvement,  18  cases 
were  described  as  on  the  way  to  cure,  29  more  had  im- 
proved under  the  treatment,  and  in  21  cases  the  growth 
had  completely  disappeared.  The  serum  was  tried  by 

1  La  Semaine  Med.,  1901,  p.  50. 
-Ibid.,  1901,  p.  69. 

3  Ibid., 1902, p.  142. 

4  Ibid.,  1900,  p.  410. 

5  La  Prcxse  Med..  1904,  Xo.  1G  (Trans.  Soc.  de  Biol.}. 


SERUM  TREATMENT  OF  TUMOURS       429 

Kirmisson l  and   by   Morgan   and   Paine 2   with   negative 
results. 

Schmidt's  serum. — Schmidt,3  of  Cologne,  prepared 
a  serum  by  inoculating  horses  and  sheep  with  cultures  of  a 
parasite  derived  from  malignant  growths,  to  which  the 
names  "  cancroidin  "  and  "  antimeristem  "  have  been  applied 
He  claims  good  results  from  this  preparation,  but  states 
that  still  greater  benefit  is  derived  from  inoculation  of  the 
actual  organisms  themselves.  The  use  of  such  a  vaccine 
is  followed  by  a  reaction  at  the  site  of  the  growth,  with 
some  accompanying  rise  of  temperature.  The  growth  of 
the  tumour  is  arrested,  and  retrogressive  changes  take  place 
in  the  cells  of  which  it  consists.  Schmidt  maintains  that 
the  parasites  isolated  by  other  observers  are  all  different 
forms  of  one  organism,  which  is  pleomorphic,  and  assumes 
different  appearances  according  to  its  conditions  of  culture. 
Trial  was  made  of  Schmidt's  serum  in  9  cases  at  the 
Middlesex  Hospital;4  it  was  not  found  to  influence  the 
course  of  the  disease.  Stockmann 5  found  that  its  use 
increased  pain  and  produced  no  apparent  benefit,  while  it 
was  very  expensive.  Kolb G  also  found  it  quite  inefficacious. 
Cytolytic  serum. — Dubois,7  who  as  early  as  1897  in- 
jected macerated  tumours  into  animals,  and  used  the  serum 
as  a  remedy,  reported  that  fibrosis  was  thereby  induced  in 
new  growths.  Leyden  and  Blumenthal 8  endeavoured  to 
prepare  a  cytolytic  serum  by  injecting  rabbits  with  finely 

1  La  Semaine  Med.,  1905,  p.  361. 

2  Lancet,  1906,  i.  955. 

3  An  account  of  Schmidt's  work  was  given  by  Dr.  H.  J.  Johnson 
at  the  Abernethian  Society  of  St.  Bartholomew's  Hospital,  Nov.   5, 
1903.     (See  Lancet,  1903,  ii.  1374.) 

4  Lancet,  1904,  ,i.  684.      Gf.  Power  (Brit.  Med.  Journ.,  1904,  i. 
299),  who  found  that  the  serum  produced  an  inflammatory  reaction 
but  did  not  influence  malignant  growths. 

5  Abstr.  in  Zeitschr.f.  Immunitatsforseh,,  1913.  p.  286. 

6  Serl.  klin,  Woch.,  1912,  No.  17. 

7  Eev.  Med.  de  VEst,  Feb.  1,  1897. 

8  Dent,  nwd,  Woch.,  Sept.  4,  1902. 


430       SERUMS,    VACCINES,    AND    TOXINS 

divided  tumours  taken  from  dogs.  They  considered  that 
they  had  good  results  in  dogs  affected  with  tumours,  which 
received  injections  of  the  serum  of  the  rabbits  thus 
prepared.  The  serum  was  subsequently  tried  on  human 
patients,  carcinoma-cells  from  human  sources  being  used 
for  the  preparation  of  the  serum.  The  writers  state  that 
benefit  was  derived  from  the  injections  in  some  inoperable 
cases. 

J.-B.  Charcot1  tried  a  similar  serum,  but  admits  that 
the  results  obtained  were  open  to  question.  Some  local 
reaction  was  produced  by  the  serum  at  the  seat  of  the 
tumour.  The  injections  were  not  painful. 

With  regard  to  the  use  of  serums  of  this  nature,  we  are 
met  by  the  difficulty  that  at  present  no  proof  is  available 
that  the  cells  of  an  epithelial  tumour  are  of  a  different 
nature  from  those  of  the  normal  epithelium  from  which  they 
are  derived.  Hence  it  is  impossible  to  know  whether  it  is 
practicable  to  produce  effects  on  the  cells  of  the  tumour  with- 
out the  simultaneous  occurrence  of  destructive  changes  in 
normal  cells.  The  best  hope  in  this  respect  seems  to  lie  in 
the  recognized  lack  of  resistance  met  with  in  the  cells  of 
tumours,  which,  in  spite  of  their  rapid  growth,  or  perhaps 
in  consequence  of  it,  are  liable  to  undergo  early  degenera- 
tion. It  is  possible  that  a  weak  destructive  force,  such  as 
might  be  supplied  by  an  epitheliolytic  serum,  might  suffice 
to  kill  tumour-cells,  while  unable  to  affect  injuriously  cells 
of  normal  resistance.  The  effects  of  the  cytolytic  serums  at 
present  prepared  do  not  appear  to  be  very  potent. 

CANCROi'N  AND  SIMILAR  PREPARATIONS 
Adamkiewicz  -'  has  prepared  an  extract  of  cancers  with 
which  he  claims  to  have  had  astonishingly  good  results  in 
cases  of  cancer.  The  extract  is  said  to  consist  principally 
of  neurine  with  some  preservative  fluid.  He  reported 
cases  of  cancer  of  the  tongue,  oesophagus,  stomach,  larynx, 

1  La  Semaine  Med.,  1900. 

*  Berl.  klin.  Woch.,  1902,  No.  24. 


CANCROIN  431 

and  breast  in  which  great  improvement  was  effected  by 
his  preparation  ;  and  Kretzmer  l  records  another  case  of 
oesophageal  cancer  which  rapidly  improved  under  injections 
of  cancroin. 

Very  severe  criticisms  of  the  cases  recorded  by  Adani- 
kiewicz  were  made  by  JSTothnagel  and  others.  It  was  pointed 
out  that  the  diagnosis  of  cancer  was  not  definitely  made  in 
any  one  of  the  cases.  Carcinoma  of  the  stomach  is  a  con- 
dition which  it  is  very  difficult  to  diagnose  with  certainty, 
and  the  patient  who  was  said  to  be  suffering  from  this  disease 
and  to  be  benefited  by  the  cancroin  subsequently  came  back 
again  for  treatment  for  vomiting.  In  cases  of  cancer  of  the 
(.esophagus,  pieces  of  the  growth  may  at  times  slough  off 
and  so  leave  a  passage  for  food,  rendering  swallowing  once 
more  possible  for  a  period  of  time.  This  may  have  occurred 
in  the  cases  recorded  above,  and  the  temporary  benefit  have 
been  ascribed  to  the  cancroin. 

Poten2  failed  to  obtain  any  improvement  in  two  cases 
(cancer  of  breast  and  of  uterus)  in  which  he  employed 
cancroin.  He  points  out  that  it  is  of  no  use  to  record  cases 
of  improvement  under  this  or  any  other  remedy  unless  the 
diagnosis  is  confirmed  by  microscopical  evidence. 

It  is  almost  impossible  to  believe  that  a  remedy  of  the 
composition  assigned  to  cancroin  can  have  any  real  effect  on 
malignant  growths.  Much  more  definite  evidence  than  that 
at  present  available  will  have  to  be  forthcoming  before  the 
claims  of  this  cure  for  cancer  can  be  taken  seriously. 

An  extraordinary  variety  of  cellular  preparations 
have  been  tried  in  cancer.  Thus  Vaughan  3  used  a  residue  left 
after  extraction  of  ground-up  cancer- cells  with  water,  saline 
solution,  alcohol,  and  ether ;  he  believed  that  thereby  the 
growth  of  some  superficial  tumours  was  checked  and  pain 
diminished.  Rovsing  4  administered  a  fluid  expressed  from 

1  Petersburg,  med.  Woch.,  1902,  No.  20. 
-  Berl.  klin.  Woch.,  1902,  No.  28. 

3  Med.  Record,  1910,  Ixxvii.  892. 

4  Ibid.,  1911,  Ixxix.  29. 


432       SERUMS,    VACCINES,    AND    TOXIN, S 

the  patient's  own  tumour,  and  thought  he  saw  beneficial 
results  in  2  cases.  Oilman  and  Coca,  at  the  Philippine 
General  Hospital,  used  emulsions  of  living  cancer-cells  ;  but 
Risley  1  found  that,  so  far  from  checking  the  growth,  such 
treatment  might  even  accelerate  it.  Ill  and  Minuingham  - 
employed  injections  of  ascitic  fluid  from  a  case  of  cancer 
affecting  the  peritoneum,  and  noted  some  subjective  im- 
provement— this  seems  to  occur  with  almost  any  remedy 
which  excites  new  hopes — but  no  cases  of  cure. 

VACCINE  TREATMENT 

Doyen  is  perhaps  alone  in  regarding  the  Micrococcus 
iieoformans  as  the  ultimate  cause  of  malignant  growths, 
but  it  is  an  undoubted  fact  that  this  variety  of  staphylo- 
coccus  is  very  frequently  associated  with  secondary  sup- 
purations, and  the  use  of  a  vaccine  in  doses  of  100  to  250 
millions  is,  under  such  conditions,  of  considerable  value. 
Jacobs  and  Geets  3  treated  37  cases  of  carcinoma  of  the 
breast  thus,  with  more  or  less  improvement  in  26. l 

Summary. — The  most  remarkable  fact  about  the 
various  serums  and  remedies  above  alluded  to  is  that  they 
all  seem  to  have  produced  good  results  in  the  hands  of 
their  inventors,  but  few,  if  any,  of  them  appear  to  have 
succeeded  iii  those  of  others.  The  only  one  which  can  be 
said  to  have  established  any  pretence  to  efficacy  is  Coley's 
fluid,  which  has  been  tried  now  in  a  sufficient  number  of 
cases  to  afford  material  for  forming  a  judgment.  It  appeal's 
to  be  definitely  established  that  erysipelas  may  cause  the 
disappearance  of  malignant  growths,  especially  sarcomas; 
and  the  records  of  cases  treated  by  Coley's  toxins  give 
ground  for  hope  that  the  use  of  the  toxins  may  be  followed 
by  similar  good  effect  without  the  dangers  of  the  actual 

1  Boston  Med.  and  Surg.  Journ.,  Nov.  23,  191 1 . 

2  Journ.  Atner.  Med.  Assoe.,  Aug.  17,  1912. 
•i  Lancet,  1906,  i.  964. 

4  See  alto  above,  under  "  Schmidt's  serum,"  p.  429. 


MALIGNANT   TUMOURS  433 

inoculation  with  bacteria.  The  treatment  is  certainly  worthy 
of  trial  in  cases  which  are  beyond  the  aid  of  the  surgeon. 
It  is  most  important,  however,  to  recognize  that  no  time 
should  be  lost  in  medicinal  treatment  of  any  kind,  if  there 
is  a  possibility  of  removing  the  growth  with  the  knife. 
This  remains  at  present  the  only  method  which  holds  out 
reasonable  hopes  of  cure  in  malignant  disease. 

CONCLUSIONS 

1 .  Coley's    fluid    may  be    tried   in   inoperable  cases  of 
malignant  disease,  especially  of  sarcoma.     It  should  not  be 
used  as  a  temporizing  measure  in  cases  which  are  amenable 
to  surgical  interference. 

2.  Until  it  is  proved  that  cancer  is  an  infective  disease, 
serum  treatment  of  the  usual  kind  is  inapplicable  to  this 
condition.     It  is,  however,  permissible  to  hope  that  it  may 
be  possible  to  produce  a  cytolytic  serum  which  may  act  on 
the  cells  of  the  growth  without  affecting  the  normal  cells  ©f 
the  tissues.     A  satisfactory  serum  of  this  nature  does  not 
appear  to  have  been  as  yet  prepared. 

3.  In    secondary    suppurative   infections   of   malignant 
growths  a  vaccine  of  the  responsible   organisms — whether 
Micrococcus  neoformans,  or  other  bacteria — will  frequently 
relieve  certain  of  the  more  distressing  symptoms. 


2c 


APPENDIX 

VARIOUS    CONDITIONS    TREATED    WITH 
SERUMS,    ETC. 

THERAPEUTIC    USE    OF    NORMAL    HORSE-SERUM,    ETC. 

MONTGOMERY  PATON,*  as  a  result  of  trial  of  diphtherial 
antitoxic  serum  in  diseases  other  than  diphtheria,  was  led  to 
believe  that  the  serum  or  plasma  of  normal  (untreated)  ;uii- 
malshad  a  definite  effect  in  raising  the  power  of  resistance 
to  infective  conditions.  He  prefers,  however,  the  serum  of 
horses  which  have  undergone  a  slight  degree  of  immunization 
against  diphtherial  toxins,  as  by  this  procedure,  which  acts 
by  raising  the  resistance  of  the  tissue-cells,  the  stimulating 
effect  of  the  serum  is  increased.  His  work  in  cases  due  to 
pyogenic  infection  has  already  been  mentioned  (p.  359).  He 
finds  the  use  of  normal  plasma  also  valuable  in  tuberculosis, 
arthritis  deformans,  broncho-pneumonia,  dysmenorrhoea, 
nephritis,  cerebro-spinal  meningitis,  epilepsy,  Graves's  dis- 
ease, traumatism,  and  other  conditions.  The  serum  is  given 
by  the  mouth.  The  list  of  diseases  for  which  it  is  useful 
is  rather  too  long  and  varied  for  the  claims  made  on  its 
behalf  to  be  very  convincing. 

Schmidt 2  and  Borchardt 3  have  injected  normal  serum 
into  the  peritoneal  cavity  before  operations  on  the  abdomen, 
with  a  view  to  increasing  the  resistance  to  any  accidental 
septic  infection ;  and  Stuart  Low 4  suggests  the  use  of 
serum  as  a  dressing  for  wounds.  Hort5  advises  the  use  of 

1  "New  Serum  Therapy."     London,  1906. 
"  Dent.  med.  Woch.,  1904,  No.  49.  s  Ibid. 

4  Lancet,  1907,  i.  1221.  •>  Ibid.,  1908,  ii.  462. 

434 


NORMAL    SERUM  435 

serum,  given  by  the  mouth,  in  cases  of  gastric  ulceration, 
and  H.  D.  Rolleston  confirms  his  results  so  far  as  relief  of 
pain  and  of  haemorrhage  is  concerned. 

Latham 1  has  used  horse-serum  by  the  mouth  in  cases  of 
pidmonary  tuberculosis  along  with  tuberculin,  and  attributes 
good  effects  to  the  remedy.  We  have  not  been  able  to 
satisfy  ourselves,  however,  that  the  serum  has  any  definite 
value  in  this  disease. 

Weil  2  made  trial  of  injections  of  the  serum  of  normal 
individuals  and  of  animals  in  cases  of  hcemophilia,  with  a 
view  to  supplying  the  coagulating  substance  which  is  want- 
ing in  these  patients,  and  found  that  improvement  resulted. 
His  observations  are  confirmed  by  Broxa,3  who  states  that 
normal  serum  may  be  given  to  these  patients  as  a  prophy- 
lactic against  attacks  of  bleeding,  and  finds  that  diphtherial 
antitoxic  serum,  which  is  generally  at  hand,  is  effective. 
Ridder  found  serum  treatment  useless  in  a  family  of 
bleeders.4 

It  is  worthy  of  note  that  Cole  and  Smirnow 5  find 
experimentally  that  foreign  serum  may  in  some  instances 
favour  infection.  Thus,  if  the  serum  of  pigeons  be  injected 
into  mice  along  with  cultures  of  pneumococci,  the  animals 
succumb  more  readily  to  the  parasite,  though  pigeons  under, 
normal  circumstances  are  immune  to  the  pneumococcus. 

Clars 6  has  used  diphtherial  antitoxic  serum  in  purpura 
hcemorrhagica,  followed  by  normal  horse-serum.  Bigelow 7 
uses  fresh  rabbit's  serum  in  the  hscmorrhagic  disease  of 
new-born  infants.  Dewar 8  believes  that  it  was  of  benefit 
in  a  case  of  hemoptysis.  Levison 9  recommends  the  local 

1  Proc.  Roy.  Soc.  Med.,  1908. 

-  Compt.  Rend.  Acad.des  Set.,  cxli.,Nos.  Id,  17. 

3  Med.  Klinik,  1907,  p.  1445. 

4  Charlie  Ann.,  1910. 

5  Johns  Hopkins  Hosp.  Bull.,  Sept.,  1908,  p.  249. 

6  Med.  Eecord,  1910,  Ixxvii.  642. 

7  Journ.  Amer.  Med.  Assoc.,  July  30,  1910. 
s  Brit.  Med.  Journ.,  1909,  ii.  1664. 

u  Journ.  Amei'.  Med.  Astsoc.,  March  8,  1913. 


436       SERUMS,    VACCINES,    AND   TOXINS 

application    of   horse-serum    in    cases    of    bleeding    after 
operation. 

MORPHINE    ANTITOXIN,    KT<  . 

It  was  stated  in  the  first  chapter  of  this  book  that 
the  ordinary  mineral  and  vegetable  poisons,  such  as  arsenic 
or  morphine,  do  not  give  rise  to  the  formation  of  anti- 
toxins ;  and  this  is  the  view  generally  held.  Hirschlaff, l 
however,  claimed  to  have  succeeded  in  producing  an  anti- 
toxic serum  which  would  counteract  poisoning  by  morphine. 
He  injected  gradually  increasing  doses  of  the  alkaloid  into 
rabbits,  and  obtained  their  serum.  He  then  ascertained 
exactly  the  minimal  lethal  dose  of  morphine  for  a  rabbit 
per  kilogram  of  body  weight,  and  found  that,  if  some  of  the 
serum  was  administered  along  with  the  poison,  the  animals 
were  able  to  survive  a  larger  amount  of  the  poison  than  if 
no  serum  was  given.  The  serum  was  also  capable  of  pro- 
tecting mice  against  the  poison.  Further,  Hirschlatf  found 
that  if  an  emulsion  of  brain-substance  was  mixed  with  the 
morphine,  larger  doses  of  the  latter  could  be  tolerated  ;  from 
this  he  concludes  that  the  brain-cells  have  a  power  of 
fixing  this  poison  similar  to  that  which  they  exhibit  towards 
the  toxin  of  tetanus.  In  a  (human)  case  of  morphine 
poisoning  which  he  observed,  Hirschlaff  made  use  of  some 
of  the  antitoxic  rabbit's  serum,  and  considered  that  it  had 
a  distinct  antidotal  action.  He  also  found  it  useful  in 
enabling  patients  who  have  formed  a  morphine  habit  to 
leave  off'  the  drug  at  once,  the  severe  nervous  symptoms 
which  usually  occur  in  such  circumstances  not  being  ex- 
perienced. 

HirschlafFs  statements  were  severely  criticized  by  Mor- 
genroth,2  and  it  is  probable  that  his  conclusions  were 
founded  on  errors  of  observation. 

An  anti-alcoholic  serum  has  been  prepared  by  Sapelier 
and  Dromard,  but  at  present  it  is  difficult  to  take  the  claims 

1  Berl.  klin.  Woch.,  Dec.  8  and  15,  1902. 
-  Ibid.,  1903,  No.  21. 


EXOPHTHALMIC   GOITRE  437 

of  the  preparation  very  seriously.1  The  effects  of  serum 
derived  from  herbivorous  animals  in  cases  of  strychnine 
poisoning  have  been  investigated  by  Lo  Monaco,2  who 
suggests  the  use  of  diphtherial  antitoxin  in  this  condition. 

ANTIABR1N   SERUM 

Jequirity  has  been  used  in  ophthalmic  practice  to  induce 
inflammation  in  eyes  which  are  affected  with  chronic 
indolent  conditions  (pannus,  etc.).  Difficulties  frequently 
arise  owing  to  the  impossibility  of  graduating  the  amount 
of  inflammation  produced.  It  has  been  found  possible, 
however,  by  instillation  of  a  serum  3  prepared  by  injecting 
animals  with  abrin,  the  active  principle  of  jequirity,  to  con- 
trol the  inflammatory  reaction  produced  by  preparations  of 
this  plant. 

GRAVES'S  DISEASE  (EXOPHTHALMIC  GOITRE) 

In  this  disease  the  principle  upon  which  serum  treatment 
is  founded  is  different  from  that  in  most  of  those  previously 
considered,  since  the  serum  is  used  to  neutralize  a  poison 
formed  by  the  cells  of  the  patient  himself,  not  by  any  para- 
sitic organisms.  The  treatment  is  in  reality  of  the  nature 
of  "  organotherapy  "—administration  of  animal  organs  or 
extracts.  Since,  however,  it  is  serum  which  has  been  used 
in  some  cases,  it  demands  notice  here. 

Etiology. — The  causation  of  this  disease  is  not  well 
understood.  Serum  treatment  is  suggested  on  the  ground 
that  in  all  probability  the  disorder  is  due  to  an  auto-intoxi- 
cation caused  by  an  excess  of  the  secretion  normally  formed 
by  the  thyroid  gland.  The  enlargement  of  this  structure  is 
a  frequent,  though  not  an  invariable,  feature  of  the  disease, 
which  may  apparently  exist  in  an  abortive  form,  lacking 

1  An  abstract  of  the  authors'  observations  may  be  found  in  the 
Journ.  de  Med.  et  de  Cliir.  Pratiques,  June  25,  1903,  p.  461. 

2  Arch.  Ital.  de  Biokgia,  June  10,  1903. 

3  See  Dieudonne,  "  Immunitat,  Schutzimpfung  u.  Serumtherapie," 
p.  121.     Leipzig,  1903. 


438       SERUMS,    VACCINES,    AND    TOXINS 

any  one  or  even  two  of  its  main  features  (tachycardia, 
exophthalinos,  and  enlargement  of  the  thyroid  gland). 

Lanz's  milk  treatment. — The  first  experiments  in  the 
direction  of  the  treatment  of  Graves's  disease  by  means  of 
preparations  derived  from  animals  which  had  had  the 
thyroid  gland  removed  were  made  by  Lanz,1  who  performed 
thyroidectomy  on  goats,  and  treated  cases  of  exophthalmic 
goitre  with  their  milk.  He  has  recorded  altogether  six 
cases  in  which  this  treatment  alone  was  adopted,  and  states 
that  the  results  were  very  encouraging.2  As  an  instance, 
we  may  quote  the  case  of  a  woman  aged  38,  who  exhibited 
the  characters  of  the  condition  in  a  very  marked  degree. 
There  were  wasting  and  tremor,  enlargement  of  the  heart 
and  tachycardia  (160  per  minute),  and  cederna  of  the  lower 
limbs.  Exophthalmos  was  well  marked  and  von  Graefe's 
sign  present.  The  characteristic  thrill  was  perceptible  over 
the  thyroid  gland,  which  was  much  enlarged.  The  patient 
was  very  weak  and  depressed,  and  slept  badly.  The  milk 
treatment  was  carried  out  in  hospital  for  five  weeks,  at  the 
end  of  which  time  very  marked  improvement  had  occurred. 
The  woman  felt  much  stronger,  and  could  now  walk  about, 
which  she  could  not  do  before.  She  was  supplied  with  a 
goat  from  which  the  thyroid  gland  had  been  removed,  and 
continued  the  treatment  at  home.  At  the  end  of  a  year 
she  was  apparently  quite  cured.  Lanz  states  that  he  had 
never  seen  a  cure  effected  previously  in  a  patient  who  had 
reached  the  stage  of  the  malady  presented  by  this  case. 

Goebel 3  also  has  recorded  a  case  of  cure  with  the  milk 
treatment,  but  as  the  patient  was  given  arsenic  as  well  it 
is  impossible  to  be  certain  that  the  good  result  was  due  to 
the  milk. 

A  desiccated  milk  derived  from  thyroidectomized 
animals  has  been  prepared  by  Burghart  and  Blumenthal, 
under  the  name  of  "  rodagen."  It  is  said  to  be  efficient, 

1   Correspondcnzblatt  f.  Schweizer  Aerzte,  1899,  No.  23. 
*  Munch,  med.  Jf'och.,  1903,  p.  146. 
3  Ibid.,  1902,  No.  20. 


EXOPHTHALMIC   GOITRE  439 

but  acquires  an  unpleasant  cheesy  smell  and  taste  on 
keeping  (Moebius).  Personal  trial  and  observation  do  not 
suggest  chat  it  is  very  effective. 

Serum  treatment.— Ballet  and  Henriquez  l  and  Burg- 
hart  and  Blumenthal 3  have  used  the  serum  of  dogs  from 
which  the  thyroid  gland  had  been  removed,  for  the  treat- 
ment of  the  malady,  and  they  all  record  good  results. 
Moebius 3  has  made  use  of  the  serum  of  rams  which  had 
been  similarly  treated.  Hypodermic  injection  was  first 
employed,  but  was  given  up  as  unsatisfactory  ;  and  adminis- 
tration by  the  mouth  was  substituted.  Moebius  gives  5c.c. 
of  the  serum  every  other  day  in  a  tablespoonful  of  wine. 
He  noted  a  rapid  diminution  in  the  size  of  the  thyroid 
gland  in  his  patients,  with  diminished  frequency  of  the  pulse 
and  cessation  of  the  tremor.  No  ill  effects  were  observed. 

Schultes  4  also  tried  this  remedy,  giving  smaller  doses 
at  shorter  intervals  (0'5  c.c.  three  times  a  day).  These 
amounts  were  gradually  raised  by  daily  additions  of  O5  c.c.  to 
each  dose,  till  the  patients  were  taking 4*5  c.c.  three  times  a 
day.  Sclmltes  first  used  sherry  as  a  vehicle,  and  afterwards 
raspberry  syrup.  He  noted  the  same  good  results  as  were 
claimed  by  Moebius,  the  pulse  falling  from  142  to  90  beats 
a  minute,  and  the  circumference  of  the  neck  diminishing  to 
almost  normal  proportions. 

Dreschfeld  5  records  his  experience  of  the  serum  in  21 
cases,  of  which  10  were  cured  and  6  improved.  He  gave 
doses  of  10  minims  by  the  mouth  thrice  daily,  gradually 
raising  the  dose  to  20-25  minims. 

Hallion6  has    used   a   glycerinated  preparation  of  the 

1  Semaine  Med.,  1895,  p.  329. 

2  Deut.  med.  Wpch.,  1899, Nos.  37,  38.    V.  Leyden's  "Festschrift," 
p.  251 ;  Berlin,  1902. 

3  Schmidt's  Jahrbuchd.  ges.  i¥«/.,cclxxiii.  43;  Munch,  med,  Woch. 
1903,  No.  4,  p.  149. 

4  Munch,  med.  Woch.,  1902,  No.  20,  p.  834. 

5  Med.  C'/tron.,  1906,  xliv.  203. 

6  La  Presse  Med.,   Nov.  1,  1905, 


440       SERUMS,    VACCINES,    AND    TOXINS 

whole  blood  of  thyroidectomized  animals  (hsematoethyroi- 
dine),  and  a  preparation  known  as  "  thyroidectin  "  is  of 
somewhat  similar  constitution. 

Stradiotti l  prepared  a  thyrotoxic  serum  by  injecting  a 
sheep  with  powdered  thyroid  glands,  and  used  it  for  the 
treatment  of  patients  suffering  from  Graves's  disease, 
the  doses  being  from  5  to  4.5  c.c.  Subjective  improve- 
.  ment  and  diminution  of  the  tremor  resulted,  but  the  cardio- 
vascular condition  was  not  influenced. 

In  America  a  serum  prepared  by  Beebe  is  in  use ;  it  is 
made  by  injecting  an  extract  of  finely  powdered  thyroid 
glands  into  animals,  the  extract  containing  nucleo-proteins 
and  globulins.  The  serum  is  standardized  by  measuring 
its  power  of  agglutinating  small  fragments  of  thyroid 
gland.2 

The  exact  mode  in  which  the  milk  or  serum  acts  is  not 
quite  clear.  That  it  must  somehow  counteract  the  excess 
of  thyroid  secretion  is  evident ;  but  it  can  hardly  be  sup- 
posed that  the  mere  injection  of  so  small  a  quantity  of 
serum  free  from  this  substance  could  reduce  the  proportion 
of  it  present  in  the  blood  of  a  patient  suffering  from  Graves's 
disease  to  a  point  below  that  at  which  toxic  symptoms 
occur.  There  must  be  some  actively  antagonistic  principle 
in  the  serum  or  milk  of  the  thyroidectomized  animal  which 
acts  as  antitoxin.  It  appears  that  symptoms  of  intoxica- 
tion occur  both  when  there  is  defect  and  when  there  is 
excess  of  thyroid  secretion  ;  poisonous  substances  are  set 
free  which  neutralize  each  other  in  health.  In  other  words, 
the  function  of  the  thyroid  gland  must  be  the  preparation 
of  a  substance  which  neutralizes  a  poison  formed  by  the 
other  tissues  of  the  body  in  the  course  of  their  activity.  It 
would,  however,  be  premature  to  form  definite  conclusions 
as  to  the  etiology  of  Graves's  disease  on  the  strength  of  the 
very  small  number  of  cases  which  are  at  present  available 
as  evidence  of  the  curative  properties  of  the  serum  of 

1  Riv.  Crit.  di  Clin.  Med.,  1907,  Nos.  7  and  8. 

2  Jonrn.  Amer.  Med.  A-ssoc.,  Sept.  1,  1906. 


LEUCH^MIA  441 

thyroidectomized  animals.  From  the  practical  point  of 
view,  even  should  the  treatment  be  proved  successful,  there 
would  still  remain  the  serious  consideration  of  expense  in 
connection  with  it.  Moebius  records  that  in  one  of  his 
cases  the  cost  worked  out  at  400  marks  (£20). 

Burkard l  gave  dlphtherial  antitoxin  in  doses  of  3,000 
units,  and  believed  that  it  had  a  good  effect.  A  similar 
observation  was  made  by  Legge.2 

LEUCH^EMIA 

This  disease,  characterized  by  anaemia  (defect  of  red 
corpuscles),  with  immense  increase  in  the  number  of  white 
corpuscles,  by  enlargement  of  the  spleen  and  of  the  lym- 
phatic glands,  and  sometimes  by  the  appearance  of  masses  of 
lymphoid  tissue  in  the  internal  organs,  is  of  uncertain  origin. 
It  is  allied  on  the  one  hand  to  the  group  of  blood-diseases, 
including  pernicious  anaemia  and  splenic  anaemia,  and  on 
the  other  hand  to  Hodgkin's  disease  (lymphadenoma)  and 
the  various  tumours. 

Injections  of  tuberculin  have  been  used  in  a  few  cases, 
apparently  with  some  diminution  in  the  number  of  leuco- 
cytes (Henck,  Beitzke).  Rolleston  has  also  administered 
antistreptococcic  serum  in  one  case  with  similar  effect,  but 
the  result  on  the  general  condition  of  the  patient  was 
inconclusive.3 

Leucatello  and  Malon4  have  used  a  leucolytic  serum 
obtained  by  injecting  animals  (rabbits,  sheep)  with  leucocytes. 
They  record  good  effects,  seen  in  diminished  number  of  leu- 
cocytes and  shrinking  of  the  spleen. 

Larrabee 5  tried  Coley's  mixed  toxins,  and  believed  the 
fluid  had  some  palliative  effect. 

1  Journ.  Amer.  Med.  Assoc.,  1906,  Nov.  3. 

2  Ibid.,  April  22,  1905. 

3  See  Susmann,    "Leuchaemia  and   Tuberculosis,"   Practitioner, 
1903,  ii.  541. 

4  Gaz.  degli  Ospedali,  1903,  No.  11. 
6  Med.  Record,  1911,  Ixxx.  1-52. 


442       SERUMS,    VACCINES,    AND    TOXINS 

Recovery  of  an  apparently  moribund  case  of  this  disease 
under  the  use  of  salvarsan  is  recorded  by  Perussia.1 

HJEMOG  LOBINURIA 

The  nature  of  this  disease  was  investigated  by  Land- 
steiner  and  Donath,2  who  ascertained  that  there  was 
present  in  these  patients  a  haemolytic  amboceptor  which 
only  acted  in  the  cold — an  unusual  condition  of  action,  as 
heat  is  commonly  needed  for  the  occurrence  of  immunity- 
reactions.  This  discovery  has  been  confirmed  by  Kumagai, 
Taizo,  and  Inoue,3  and  by  Matsuo,4  as  well  as  by  Eason/' 
who  was  credited  in  the  last  edition  of  this  book  with  the 
original  observation,  as  no  mention  of  previous  workers 
was  made  in  his  paper.  The  Wassermann  reaction  is 
positive  in  a  considerable  percentage  of  these  patients, 
suggesting  a  connection  with  syphilis. 

Widal  and  Rostanne 6  believe  that  in  this  disease 
haemolysis  occurs  owing  to  the  lack  of  an  antisensibilisatrice 
(anticopula)  which  is  present  in  the  blood  of  normal  persons. 
They  tried  as  a  remedy  the  serum  of  a  rabbit  which  had 
been  injected  with  human  blood — with  a  view  to  increasing 
the  formation  of  this  body — and  believed  that  good  resulted 
from  this  mode  of  treatment. 

HODGKIN'S  DISEASE 

Frankel  and  Much  ">  believe  that  a  bacillus  found  in  the 
lesions  is  the  cause  of  this  malady.  It  is  a  Gram-positive 
diphtheroid  bacillus,  some  colonies  in  cultures  taking  a 
coccoid  form.  Billings  and  Rosenow  8  prepared  a  vaccine 

1  Abstr.  in  Zeitschr.  f.  Immunitatsforsch  ,  1912,  p.  600. 
-  .Uiinch.  med.  Woch.,  Sept.  6,  1904. 
8  Deut.  tned.  Woch.,  1912. 

4  Deut.  Arch.f.  klin.  Med.,  1912,  cvii.  32.'). 

5  Scot.  Med.  and  Surg.  Jottrti.,  May,  1906. 

6  Compt.  Rend.  Sue.  JSiol.,  1905,  Iviii.  321,  372. 

7  Zeitschr.  f.  Hyg.,  1910. 

8  Joitrn,  Amer.  Med.  Assoc.,  1913,  Ixi.  2122. 


PELLAGRA  443 

of  this  organism,  and  state  that  they  obtained  good  results 
in  treatment  of  cases  of  Hodgkin's  disease  therewith. 

KALA-AZAR 

The  use  of  salvarsan  in  this  disease  was  followed  in  one 
case  by  general  improvement,  with  fall  of  fever,  cessation 
of  pain,  and  shrinking  of  the  enlarged  spleen  (Caryophyllis 
and  Sotiriades).1 

ORIENTAL  SOEE 

Row  3  grew  the  causal  organism,  Leishmania,  on  Nicolle- 
Novy-McNeal  medium,  killed  the  cultures  with  glycerin, 
and  used  the  dead  culture  as  a  vaccine.  He  records  good 
results  as  obtained  in  three  cases. 

PELLAGRA 

This  disease,  characterized  by  weakness  of  the  limbs, 
ending  in  paralysis,  with  peculiar  mental  symptoms,  is, 
according  to  the  Illinois  Commission,  "  due  to  infection  by 
some  living  organism,"  but  its  exact  etiology  is  at  present 
unknown.  Many  observers  believe  it  is  due  to  the  use  of 
diseased  maize  as  food,  as  the  poison  contained  in  this 
substance  can  be  extracted,  and  is  capable  of  causing  the 
death  of  animals.  Babes  and  Manicatide3  found  that  if 
the  extract  was  injected  along  with  blood-serum  from  normal 
persons,  the  fatal  effect  was  not  prevented ;  but  that  if  serum 
from  those  convalescent  from  the  disease  were  used,  it  pro- 
tected the  animals  from  the  effects  of  the  poison.  An 
antitoxic  substance  is  therefore  contained  in  the  serum  of 
convalescents. 

Tizzoni,4  who  regards  a  streptobacillus  which  he  isolated 
from  maize,  and  also  from  the  blood  and  tissues  of  pellagrins, 
as  the  cause  of  the  condition,  states  that  an  anti-hsemolysin 

1  Deut.  med.  Woch.,  1911,  No.  41  ;  1912,  No.  34. 

2  Brit.  Med.  Journ.,  1912,  i.  540. 

3  La  Semaine  Med.,  1900,  p.  279. 

4  Centralbl.f.  Bakt.,  Orig.,  Ixvii.  175. 


444       SERUMS,    VACCINES,    AND    TOXINS 

is  present  in  the  serum  of  patients  suffering  from  pellagra, 
which  is  absent  from  normal  serum,  and  uses  a  test  based 
on  this  observation  for  the  purpose  of  diagnosis.  Salvarsan 
has  been  tried  in  cases  of  pellagra,  but  its  efficacy  is 
doubtful.* 

HYDATID   DISEASE 

Precipitation  tests. — Fleig  and  Lisbonne 2  found  that 
the  fluid  contained  in  a  hydatid  cyst  gave  a  precipitate 
when  mixed  with  the  serum  of  a  patient  suffering  from 
the  disease.  This  observation  is  confirmed  by  Welsh  and 
Chapman,3  who  use  this  reaction  as  a  means  of  diagnosis: 
12  drops  of  serum  should  be  added  to  1  c.c.  of  the  fluid. 
Different  specimens  of  hydatid  fluid  vary  in  their  power 
of  giving  the  reaction,  and  careful  selection  of  a  suitable 
sample  must  be  made  if  the  phenomenon  is  to  be  used 
as  a  test  for  the  presence  of  the  parasite.  If  the  reaction 
persists  after  operative  removal  of  a  cyst,  it  is  probable 
that  other  cysts  remain  behind ;  but  disappearance  of  the 
reaction  does  not  prove  the  disease  to  be  cured. 

Complement-fixation. — The  use  of  this  reaction  as 
a  test  for  the  presence  of  hydatid  cyst  was  first  suggested 
by  Ghedini.4  The  antigen  employed  is  either  the  fluid  from 
a  cyst  or  an  extract  of  the  membrane  forming  the  wall  of 
a  cyst.  It  appears  that  the  fluids  obtained  from  different 
specimens  of  cyst  differ  considerably  in  antigenic  properties. 
Vasr>  considers  that  fluid  from  cysts  found  in  cattle  is 
satisfactory,  but  Dobrotin6  and  Silber  and  Chmelnitzky" 
hold  that  human  cyst-fluid  must  be  used.  Halm8  states 

1  See  Nice,  MacLester,  and  Torrance,  Journ.  Amer.  Med.  Assoc,, 
March  25,  1911  ;  Cole  and  Winthrop,  ibid.,  Jan.  17,  1911. 

2  Compt.  Rend.  Soc.  Biol.,  1907,  Ixii.  1198. 

3  Lancet,  1908,  i.  1338. 

4  Gaz.  degli  OspedaU.,  1906,  p.  1907. 
r>   IFien.  med.  Woch.,  1911,  p.  251. 

6  fieri,  klin.  Woeh.,  1910,  No.  28. 

7  Abstr.  in  Z<>itxrln\f.  Tmniunitatsforsch.,  1913,  p.  800. 

8  Munch,  med.  Woch.,  1912,  p.  1483. 


HYDATID    DISEASE  445 

that  the  fluid  is  of  no  value  as  antigen,  and  that  a  watery 
extract  of  the  cyst- wall  itself  must  be  employed.  Israel1 
finds  that  the  fluid,  and  watery  or  alcoholic  extracts 
of  the  cyst,  are  equally  efficient.  Weinberg3  recommends 
that  the  test  should  be  performed  first  according  to  the 
method  of  Stern,3  with  fresh  human  serum  containing 
complement,  and  then  by  his  own  method,  with  addition 
of  guineapig's  serum.  Zappelloni  and  Kicciuti 4  found 
positive  reactions  in  all  of  33  cases,  and  other  writers  record 
useful  results.  The  reaction  may  remain  positive  for  a 
considerable  length  of  time  after  the  cyst  has  been  removed 
by  surgical  interference,  so  that  the  test  is  of  no  use  as  a 
means  of  recognizing  relapses.  A  positive  reaction  may 
occur  in  patients  infected  with  Tcenia  saginata  (Halm). 
Meyer5  denies  that  the  test  has  any  appreciable  value, 
finding  positive  reactions  in  healthy  subjects  and  negative 
in  the  infected. 

1  ZcitsoJtr.f.  Hyg.y  1910,  Ixvi.,  Heft  3. 
8  Compt.  Send.  Soc.  £iol.,  1909.  Ixvi.  816. 

3  Zeitschr.f.  Immunitatsforsch.,  1909,  p.  422. 

4  Absb.  ibid.,  1910,  p.  678. 

5  Berl.  klin.  Wocli.,  1910,  No.  28. 


INDEX 


Abrin,  5,  437 

Achorion  quinckeanum,  347 

Acne,  382 

—  indurata,  383 
Addiment,  10 
Agglutination,  13,  76 

—  diagnostic  use  of,  76 

—  group-,  81 

—  nature  of,  15 

—  of  B.  diphtherias,  136 

—  of  B.  dysenteries,  258 

—  of  B.  mallei,  204 

—  of  B.  pestis,  206 

of  B.  tuberculosis,  289 

—  of  B.  typhosus,  230 

—  of  blood-corpuscles,  13 

—  of  meningococcus,  385 

of     Micrococcus     melitensis, 

81-396 

—  of  pneumobacillus,  373 

of  pneumococcus,  373 

of  Shiga's  bacilli,  81 

of  Spirillum  obermeieri,  420 

—  of  staphylococci,  382 

—  of  streptothrix,  347 

— —  of  Vibrio  choleras,  221 

—  persistence  of,  82,  234 

test,  76 

—  macroscopic,  79 
Agglutinins,  14,  15 
Aggressins,   20 
Albuminuria  and  tuberculin,  314 

due  to  serum,  130 

Alexines,  2,  10  (see  Complement) 
Allergy  (see  Anaphylaxis) 
Amboceptor,  10 

Anaemia  after  vaccination,  191 

pernicious,  358,  419 

Anaphylaxis,  20 
Angina  redux,  128 
Anthrax,  201 
Antiabrin  serum,  437 


447 


Antianaphylaxis,  21 
Antibacterial  serum,  6,  43 
Antibodies,  10,  11 

excess  of,  37 

source  of,  33,  35 

Antibody,  use  of  word.  12 
Antigen,  12 
Antimeristem,  429 
Antimony,  preparations  of,  413 
Antiopsonins,  20 

Antiparatyphoid  inoculation,  255 
Antiphthisin,  284 
Antirabic  serum,  179 

vaccination,  171 

effects  of,  174 

results  of,  175 

Antiscarlatinal  serum,  382 
Antistreptococcic  serum,  342,  351 

ill  effects  of,  359 

in  cellulitis,  356 

in  enteric  fever,  254 

in  erysipelas,  356 

in     gangrenous     stoma- 
titis, 358 

—  in    local    collections    of 
pus,  359 

in    pernicious    anaemia, 

358 

—  in  puerperal  fever,  354 
in  purpura,  359 

— in  scarlatina,  370 

in  septicaemia,  356 

— -  in  small-pox,  199 

in    tuberculosis    of    the 

lungs,  342 

in  ulcerative   endocard- 
itis, 356 

Mannorek's,  352 

value  of,  360 

Antitoxin,  diphtherial,  98 

administration  of,  116 

ill  effects  of,  126 

• refined,  108 

—  standard  of,  100 


448 


INDEX 


Antitoxin,   diphtheria!,   statistics 
of,  110 

strength  of,  107 

unit  of,  100 

use  of  fresh,  48 

in  prophylaxis,   118 

value  of,  108 

in  paralysis,  124 

—  hay-fever,  399 

morphine,  436 

tetanus,  142 

Antitoxins,  action  of,  25,  26 
chemical  nature  of,  5 

discovery  of,  4 

formation  of,  25 

Antitryptic  value  of  serum,  423 
Antityphoid  extract  (Jez's),  244 

inoculation,  246 

serum,  235,  242 

Antivenene,  163 
dose  of,  166 

in  leprosy,  345 

standardization  of,  166 

Appendicitis,  363 
Aronson's  serum,  352 
Arseno-benzol,  414 
Arthigon,  393 

Atoxyl,  412 

Attenuation  of  bacteria,  59,  329 

Autolysins,  11 

Autumn  catarrh,  401 


B 

Bacillosine,  279 
Bacillus  anthracis,  201 

coll  communis,  262 

diphtherias,  94 

dysenteriae,  257 

emulsion,  273,  277 

enteritidis,  254 

leprae,  345 

mallei,  203 

of  whooping-cough,  266 

paratyphosus,  254 

pestis,  206 

pyocyaneus,  264 

tetani,  138 

tuberculosis,  270 

typhosus,  229 

Bactericidal  serum,  6 
Bacteriolysis,  7 

modification  of,  in  tissues,  31 

Benzidine  colours,  413 


Beraneck's  tuberculin,  286 
Blood,  human,  test  for,  90 
Boils,  383 
Botulism,  268 

Broncho-pneumonia,  379,  380 
Brnschettini's  sero-vaccine,  280 


Calf-lymph,  184 
Calmette's  antivenene,  163 

—  ophthalmic  reaction,  309 
- — -  tuberculin,  287 

Cancer  (see  Tumours) 
Cancroidin,  429 
Cancroin,  430 
Cancrum  oris,  132 
Carbuncle,  382 
Carriers,  diphtheria,  135 

—  typhoid,  254 
Catarrh,  nasal,  403 
Catarrhal  affections,  398 
Cellnlitis,  356 

Cerebral  emulsion  in  tetanus,  155 
Chantemesse's  serum,  235 
Cheloid  after  vaccination,  192 
Chemotherapy,  412 

—  of  pneumonia,  380 

—  of  relapsing  fever,  421 

—  of  syphilis,  412 
Chloroform-lymph,  185 
Cholera,  220 

— -  diagnosis  of,  221 

—  passive  immunity  to,  228 

vaccination  against,  222 

Chorea,  368 
Cobra-haemolysin,  160 
Cobra-lecithide,  161 

Cocci,  affections  due  to,  373 
Coley's  fluid,  424,  433,  441 
Colitis,  262 
Complement,  8,  10 
chemical  nature  of,  34 

deficiency  of,  38 

deviation  of,  38 

—  distribution  of,  34 

—  fixation  of,  38 

—  plurality  of,  35 
— •  source  of,  34 

Conductor,  106 

Conjunctiva,  diphtheria  of,  131 
Contratoxin,  342 

Convalescents,      serum      of,      in 
meningitis,  387 


INDEX 


449 


Convalescents,  serum  of,  in  pneu- 
monia,  376 

in  scarlatina,  371 

Copula,  8,  10 
excess  of,  38 

—  source  of,  35 
Corneal  ulcer,  376 
Coryza,  403 

Cow-pox,  identity  of,  with  small- 
pox, 183 

Crotin,  5 

Cutaneous  eruptions  due  to  se- 
rum, 128 

—  reaction,  308,  355 

in  gonorrhoea,  391 

in  puerperal  fever,  355 

—  in  syphilis,  410 
in  tuberculosis,  308 

—  in  tumours,  423 
Cyclaster  scarlatinalis,  369 
Oytase,  10 

Cytolysins,  12 

Cytolysis,  11 

Cytolytic  serum  for  tumours,  429 

Cytoryctes  variolas,  182 


Death  from  serum  injections,  57, 
127 

Denys'  tuberculin,  285 

Desmon,  10 

Diagnosis  by  complement-fixa- 
tion, 89,  295,  423 

—  by  opsonins,  83 

by      physico  -  chemical     me- 
thods, 91 

—  by  serums,  289 
—  by  toxins,  91 

by  tuberculin,  299 

by  vaccines,  391 

of  tumours,  serological,  423 

Diarrhoea,  summer,  261 
Diphtheria,  94 

active  immunization  to,  121 

—  agglutination  in,  136 

—  antibacterial  secum  for,  134 

—  as  complication,  132 

—  bacillus  of,  94 

—  conjunctival,  131,  135 

—  diagnosis  of,  136 

—  nasal,  133 

—  persistent  faucial,  75 

—  toxins  of,  96 


Diphtheria,  vaccine  treatment  of, 

135 
Diphtherial  antitoxin,  98 

—  administration  of,  116 

—  conclusions  as  to,  136 

—  discovery  of,  4 

—  dose  of,  121 

—  ill  effects  of,  126 

—  in  cancrum  oris,  132 

—  in  conjunctivitis,  131 

—  in  ear-disease,  132 

—  in  Graves's  disease,  441 

—  in  meningitis,  387 

—  in  ozsena,  133 

—  in  paralysis,  124 

—  in  pneumonia,  379 

—  in  septic  conditions,  359 

—  in  whooping-cough,  268 

—  local  use  of,  135 
manufacture  of,  98 

—  post>diphtheritic     para- 
lysis and.  124 

—  prophylactic  use  of,  118 

—  standardization  of,  100 

—  unit  of,  100 
Diplococcus  gonorrhcese,  389 

—  hemipholus,  128 

—  intracellularis,  385 

—  pneumonias,  373 
Dixon's  tuberculin,  281 
Dmegon,  393 
Dunbar's  serum,  401 
Dysentery,  257 

—  agglutination  test  in,  81,  258 

—  serum  treatment  of,  259 

—  vaccine  prophylaxis  of,  260 
— —  treatment  of,  261 


Ear-disease,  post-scarlatinal,  132 

Eel,  serum  of,  11 

Ehrlich's    theory    of    immunity, 

22 

Emmerich  and  Scholl's  serum,  427 
Empyema,  378 
Emulsion  of  tubercle  bacilli,  273, 

276 
Endocarditis,    staphylococcal,   382 

ulcerative,  356,  363 

Endocomplement,  161 
Entamoeba  dysenterioe,  257 
Enteric  fever,  229 
agglutination-test  for,  76 


450 


INDEX 


Enteric  fever,  antibacterial  serum 
in,  241,  242 

—  antistreptocoecic    serum 
in,  254 

—  antitoxic  serum  in,  235 

—  complications  of,  229 

—  diagnosis  of,  230 
—  Jez's  extract  in,  244 

—  ophthalmic  reaction,  235 

—  vaccination  against,  246 

—  vaccine     treatment     of, 
252 

Enteritis,  infantile,  261 
Epilepsy,  160 
Epiphanin   reaction,   92 
Eruptions,  cutaneous,  128 
Erysipelas  after  vaccination,   190 

—  in  tumours,  424 

—  serum  treatment  of,  356 
—  vaccine  treatment  of,  363 

Erythema,  bullous,  384 

from  serum-injections,  128 

Exophthalmic  goitre,  437 


Ferments,  protective,  21 
Ficker's  diagnostic,  80 
Fixative,  10 
Framboesia,  409,  418 
Friedmann's  tuberculin,  281 
Furunculosis,  383 


Gabritschewsky's  vaccine,  372 

Gajyl,  418 

Gastric  ulceration,  435 

General  paralysis,  408,  419 

Glanders,  203 

Glands,    swollen,    due    to    serum, 

128 

Gleet,  chronic,  394 
Globulins,    relation   of,  to   agglu- 

tinins,  17 

to  antitoxins,  5 

Gonococcus,  389 
Gonorrhoea,  75 

complement-fixation  in,  390 

cutaneous  reaction  in,  391 

serum  treatment  of,  391 

vaccine  diagnosis  of,  391 

—  treatment  of,  392 
Gonotoxin,  389 
Graves's  disease,  437 
Group-reactions,  17 


H 

Haematoethyroidine,  440 
Hsemoglobinuria,  442 
Haemolysis,  7 

—  due  to  snake-venom,  160 
Haemolytic  skin-reaction,  423 
Haemophilia,  435 
Haemoptysis,  435 
Haffkine's  cholera-vaccine,  222 

—  plague-prophylactic,  207 
Haptophore,  25 
Hay-fever.  398 

Hermanu-Perutz  reaction,   93 
Herxheimer  reaction,  415 
Hodgkin's  disease,  442 

Hogyes'  antirabic  vaccination,  174 
Horse  serum,  normal,  434 
Humoral  theory,  3 
Hydatid  disease,  444 
Hydrophobia,  168 

—  incubation  of,  170 

—  Pasteur    treatment    of,     re- 
sults of,  175 

—  serum  treatment  of,  179 

—  vaccination  against,  171 

—  virus  of,  169 
Hypersensibility,  20 

I 

Idiosyncrasy  to  serums,  130 
Immune  body,  10 
Immunity,  acquired,  30 

—  active,  30 

—  forms  of,  29 

—  maternal  transmission  of,  32 

natural,  29 

—  passive,  30 

—  theory  of,  22 
Immun  Korper,  341 
Incubation  period  of  toxins,  28 
Infantile  enteritis,  261 
Infants,  administration  of  serum 

to,  49 

Inheritance  of  immunity,  32 
Inoculation,  antityphoid,  246 

site  of,  74 

small-pox,  1 

Intermediary  body,  10 
Intracerebral  injection  of  serum, 

52,  149 

Intramine,  418 

Intramuscular    injection    of    se- 
rum, 55 


INDEX 


451 


Intraneural  injection  of  serum, 
150 

Intrathecal  injection  of  serum, 
54,  148,  387,  388 

Intravenous  injection  of  serum, 
51,  116,  148 

Iron-tuberculin,  288 

Isolysins,  11 

Italian  method  of  antirabic  in- 
oculation, 171,  180 


Jennerization,  59 

Jez's  antityphoid  extract,  244 

Joints,  pains  in,  130 

K 

Kala-azar,  443 
Keratitis,  ulcerative,  376 
Kharsivan,  418 
Klausner's  reaction,  93 
Koch's    emulsion    of    bacilli,    273, 
276 

tuberculin,  271 

Kolle's  cholera  vaccine,  223 


Lactic-acid  bacilli,  use  of,  74 
Lanz's  milk  treatment,  438 
Laryngitis,  tubercular,  326 
Lecithide,  cobra-,  161 
Leprosy,  345,  409 
Leuchsemia,  441 
Leucocidin,  381 

Leucocytes  as   source   of   comple- 
ment, 3,  33 

—  of  copula,  35 

—  in  agglutination,  17 

—  protective  action  of,  2 
Leucolysis,  161 
Leucolytic  serum,  441 

Living    tissues,    influence   of,    on 

bacteriolysis,  31 
Local  use  of  serum,  50 
Lozenges,  serum  in,  135 
Luetin  reaction,  410 
Lumbar  puncture,  54 
Lupus  vulgaris,  322 
Lustig  and  Galeotti's  vaccine,  211 
Lustig's  serum,  216 
Lymph,  vaccine,  supply  of,  193 
— —  •  preparation  of,  184 


M 

Malaria,  409,  419 

Malignant  disease  (see  Tumours) 

Mallein,  204 

Malta  fever,  81,  395 

Mandelbaum's  reaction,  235 

Maragliano's  serum,  337 

Marmorek's    serum,    antistrepto- 
coccic,  352 
• antitubercular,  339 

Maternal     transmission     of     im- 
munity, 32 

Mediator,  10 

Mediterranean  fever,  81,  395 

Meiostagmin  reaction,  92 

Meningitis,  cerebro-spinal,   385 

serum  treatment  of,  386 

—  vaccine     treatment    of, 
388 

Meningococcus,  385 
Menzer's  serum,  366 
Micrococcus  catarrhalis,  403 

—  melitensis,  395 

—  neoformans,  428,  432 

—  rheumaticus,  365 

Milk    of    thyroidectomized     ani- 
mals, 438 

—  transference     of     immunity 
by,  32 

Morbilliform  rash,  129 
Morphine  antitoxin,  436 
Mouth,    absorption    of    antitoxin 
by,  32 

—  administration  of  serum  by, 
117,  360,  439 

of  tuberculin  by,  336 

N 

Nasal  diphtheria,  133 
Nastin,  346 
Negative  phase,  69 
Neosalvarsan,  417 
Nephritis  due  to  serum,  130 
Neurotoxin,  162 
Novo-arseno-benzol,  417 

O 

Operations,  normal  serum  in,  434 
Ophthalmic  reaction,  235,  309,  402 
enteric,  235 

—  tubercular,  309 

use  of  antiabrin,  437 

Opsonin,  3,  18 


COLLtG 


'UO! 


452 


INDEX 


Opsonin,  diagnosis  by,  83 

estimation  of,  84 

Opsonin-index    after   vaccination, 

69 

meningococcic,  389 

tubercular,  83 

• value  of   estimation  of,    72, 

86 

Optochin,  380 
Oral  administration  of  serum,  117 

of  tuberculin,  336 

Oriental  sore,  443 

Otitis  media,  pneumococcic,  378 

Overproduction  theory,  25 

Oxytuberculin,  287 

Ozaena,  133 


Paralysis,  diphtheritic,  124 

general,  408,  419 

Paramelitensis  fever,  395 
Paramoecium  caudatum,  182 
Paratyphoid  infections,  254 
Pasteurization,  59 
Pasteur's     vaccine     for     hydro- 
phobia, 171 
Pellagra,  443 

Percutaneous  reaction,  308 
Periostitis,  383 
Peritonitis,  acute  diffuse,  75 

pneumococcic,  378 

tubercular,  329 

Pernicious  anaemia,  358 

Pfaundler's  reaction,  79 

Pfeiffer's  experiment,  9,  222 

Phagocytosis,  2 

Phase,  positive  and  negative,  69 

Phlogosin,  382 

Phylacogen,  69 

Piorkowsky's  tuberculin,  282 

Plague,  206 

— —  agglutination  in,  206 

Haffkine's  prophylactic,  207 

Lustig-Galeotti   vaccine,  211 

Lustig's  serum,  216 

Terni-Bandi  vaccine,  211 

— —  Yersin's  serum,  213 
Pneumobacillus,  373 
Pneumococcic  affections,  373 
empyema,  378 

endocarditis,  375 

otitis,  378 

peritonitis,  378 


Pneumonia,  chemotherapy  of,  380 

serum  treatment  of,  374 

—  vaccine  treatment  of,  377 
Pollantin,  402 
Porges'  reaction,  92 
Positive  phase,  69 
Postdiphtheritic  paralysis,  124 
Precipitation,  12 

tests,  90,  298,  444 

Precipitins,  12 

Preparateur,  10 

Preparation  of  serums,  41,  43 

Prophylactic,    Haffkine's    plague-. 

207 
immunization  in  diphtheria. 

121 
—  use  of  antitoxin,  118,  121.  151 

of  serum,  216 

of  vaccines,  59.  203.  260. 

378,  389,  397,  403,  404 
—  von  Ruck's,  278 
Prototoxoid,  103 
Protozoa,  diseases  due  to,  405 
Puerperal  fever,  354 
Puncture,  lumbar,  54 
Purpura  haemorrhagica,  359,  435 
Pus,  collections  of,  359 
Pyaemia,  pneumococcic,  378 

staphylococcic,  383 

Pyorrhoea  alveolaris,  384 


Rabies  (see  Hydrophobia) 
Rashes,  antitoxin,  128 
Reaction,  epiphanin,  92 
haemolytic  skin-,  423 

—  Hermann-Perutz,  93 

—  Herxheimer's,  415 

—  Klausner's,  93 
luetin,  410 

— •  Mandelbaum's,  235 

meiostagmin,  92 

ophthalmic,  235,  309,  402 

percutaneous.  308 

Pfaundler's,  79 

—  Porges',  92 

—  Rivalta's,  35 

Wassennann's,  405,  407 

Receptors,  24 

cholera,  227 

Rectum,  administration  of  serum 

by,  117.  358 
Relapsing  fever,  409,  420 


INDEX 


453 


Resistance,  acquired,  1 

—  of  tissue-cells,  3 
Revaccination,  187 
Rheumatism,  365 
Rhinitis,  75,  133 
Ricin,  5 

Riggs's  disease,  384 
Ringworm,  347 
Rivalta's  reaction,  35 
Rodagen,  438 

Rosenbach's  tuberculin,  282 
Roux's  point,  53 


Salvarsan,  414 

—  administration  of,  414 

—  excretion  of,  415 

—  ill  effects  of,  415 

—  in  anthrax,  203 

—  in  dysentery,  257 

—  in  hydrophobia,  181 

in  kala-azar,  443 

—  in  pellagra,  443 

—  in  small-pox,  200 

—  in  syphilis,  412,  414 
in  yaws,  418 

—  intrathecal  injection  of,   419 

—  substitutes  for,  417 
Sarcoma,  Coley's  fluid  in,  426 

Wassermann  reaction  in,  409 

Scarlatin,  370 

Scarlatina,  369,  409 

serum  treatment  of,  370 

— •  vaccine  treatment  of,  372 
Scarlatinal  ear-disease,  132,  371 
Scarlatiniform  rash,  129 
Sclavo's  serum,  201 
Sedimentation  test,  79 
Sensitized  corpuscles,  11 

vaccines,  67 

Sensitizing  substance,  10,  11 
Septic      conditions,       diphtherial 

antitoxin  in,  359 
Septicaemia,  356 

gonorrhoeal,  392 

Sero-vaccine,  Bruschettini's,  280 
Serum,  administration  of,  41,  46, 

50 

antiabrin,  437 

— — •  antiamarillic,  266 
— —  antianthrax,  201 

—  antibacterial,  6,  43 

anticancerous,  427 


Serum,  anticrotalus,  165 

—  antidysenteric,  259 

—  antileprous,  345 

—  antimeningococcic,  386 

—  antiplague,  213,  216 

—  antipneumonic,  374,  388 

—  antirabic,  179 

—  antirheumatic,  366 

—  antiscarlatinal,  370 

antistaphylococcic,   382 

—  antistreptococcic,  342,  351 

—  antitoxic,  preparation  of,  6, 
41 

—  antitubercular,  337 

—  antityphoid,  235 

—  bactericidal,  6 

—  Carrasquilla's,   345 

—  Chantemesse's,  235 

—  cytolytic,  429 

—  Deutsch's,  203 

—  dose  of,  47 

—  Doyen's,  428 

—  Dunbar's,   401 

—  Emmerich  and  Scholl's,  427 

—  for  B.  coli,  263 

—  for  B.  pyocyaneus,  264 

—  for  Graves's  disease,  440 

—  for  Mediterranean  fever,  396 

—  for  relapsing  fever,  421 

—  for  syphilis,  411 

—  for  whooping-cough,  267 

—  haemolytic  action  of  foreign, 
11 

—  homologous,  44 

—  horse-,  normal,  434 

—  idiosyncrasy  to,  130 

-  ill  effects  of,   55,  126,  359 

—  immune,  12,  19 

—  leucocytic,  441 

—  Leuriaux's,  267 
local  use  of,  50 

Lustig's,  216 

MacConkey's,  218 

—  Maragliano's,  337 

—  Marmorek's,  339,  352 
Mendez's,  203 

—  Menzer's,  366 

—  Moser's,  370 

—  of     convalescents,     371,    376, 
387 

—  of   immune  cattle  in  small- 
pox, 199 

of      thyroidectomized      ani- 
mals, 439 


454 


INDEX 


Serum,  oral  administration  of,  50 

polyvalent,  44 

—  preparation  of,  41 

—  protective  power  of,  2 

—  rashes,  57 

—  rectal  administration  of,  117, 
340,  358 

— -  Romer's,  375 

—  Schmidt's,  429 
— -  Sclavo's,  201 

—  sickness,  57 

—  standardization  of,  45 

—  testing  of,  44 

thyrotoxic,  440 

-  treatment,  theory  of,  41 

nse  of  fresh,  48 

of  warm,  131 

Wlaeffs,  427 

Yersin's,  213 

Shock,  anaphylactic,  20 
Side-chain    hypothesis,    23 
Site  of  inoculation.  74 
Small-pox,  182 

complications  of,  183 

identity    of,    with    cow-pox, 

183 
inoculation  against,  1 

modified,  198 

serum  treatment  of.   199 

vaccination   against,   183 

Snake-bite,  157 

Snakes,  varieties  of  poisonous,  157 
Snake-venom,  158 
Specific  nature  of  antitoxins,  5 
Spirillum  cholera*,  220 

obermeieri,  420 

Spirochaeta  obermeieri,  420 

pallida,  405 

Sporotrichum  beurmanni,  347 
Stages  of  phthisis,  318 
Staphylococci,  affections   due  to, 

381 

toxins  of.  381 

Stimulins,  18 

Stomatitis,  gangrenous,  358 

Streptococci,    affections    due    to, 

349 

Streptococcic  vaccine,  362 
Streptococcus  faecalis,  364 
pyogenes.  351 

rheumaticuB.  365,  366 

Streptotrichosis,  347 
Subcutaneous  injection  of  serum, 

50 


Snbdural  injection,  148 
Substance  sensibilisatrice,  10,  11 
Supersensibility,  20 
Sycosis,  383 
Syncoccus,  393 
Syphilis,  405 

—  chemotherapy  of,  412 
from  vaccination,  190 

—  serum  reaction  in,  405 
— treatment  of,  411 

Wassermann      reaction      in. 

405,  408 
Syringe  for  serum,  48 

for  vaccines,  73 

sterilization  of,  49 


Tabes  dorsalis,  408 

Tebean,  289 

Terni  and  Bandi's  vaccine,  211 

Test,  agglutination,  14,  76,  79 

—  Calmette's,  309 

—  cutaneous,  308,  355 

—  precipitation,  90 

—  sedimentation,  79 

—  von  Pirquet's,  307 

Wassermann's.  408 

—  Wassermann-Uhlenhuth.  90 

Widal's,  76,  231 

sources  of  error  in,  231 

(see  also  Eeaction) 

Tetanine,  141 

Tetanolysin,  141 
Tetanus,  138 

antitoxin,  142 

administration    of. 


151 


156 


144 


147. 


dose  of.  151 
ill  effects  of.  154 
preparation  of,  142 
prophylactic  use  of,  151, 

standardization  of.  142 

statistics  of,  146,  152 

unit  of,  143 

nse  of.  145 

value  of,   experimental. 


cerebral  emulsion   in,   155 

from  vaccination,  190 

toxins  of,  29,  140 

Thyroidectin,  440 

Tissues,  fixation  of  toxins  by.  35 


INDEX 


455 


Tissues,  influence  of,  on  bacterio- 
lysis, 34 

resistance  of,  3 

Tonsillitis  due  to  serum,  128 

Toxins,  absorption  of,  by  mouth, 
33 

—  action  of,  27,  28 

—  as  curative  agents,  68,  426 

—  as  diagnostic  agents,  91 

—  incubation  period  of,  28 

—  interaction   with   antitoxins, 
101 

—  of  B.  coli,  263 

—  of  B.  diphtheria,   96 
of  B.  dysenteriae,  257 

of  B.  icteroides,  265 

of  B.  mallei,  204 

—  of  B.  pyocyaneus,  264 

—  of  B.  tetani,  140 

of  B.  tuberculosis,  271 

—  of  B.  typhosus,  230 

—  of  gonococcus,  389 

—  of  hay-fever,  399 

—  of  staphylooocci.  381 

—  of  streptococci,  351 
— •  of  V.  choleras,  220 

Toxones  and  toxoids,  103 
Toxophore,  25 
Treponema  pallidum,  405 
Tricophyton  holosericum,  282 
Trixidine,  413 
Trypan-red  and  -blue,  413 
Tuberal,  279 
Tuberculin,  68,  271 

—  action  of,  273 

—  administration  of,  332 

-  .1  Ikalimim,  273 
alt,  271 

-  Beraneck's,  286 

—  bovine,  278 

—  by-effects  of,  314 
Calmette's,  287 

-  choice  of,  333 
composition  of,  272 

—  contraindications,  304 
Denys',  285 
diagnostic  use  of,  83,  299 

-  Dixon's,  281 

-  dosage  of,  334 
—  Priedmann's,  281 

—  in     disease     of     bones     and 
joints,  327 

—  in     genito-urinary     disease, 
329 


Tuberculin  in  leprosy,  346 

—  in  leuchaemia,  441 

—  in  lupus,  322 

—  in  ophthalmic  disease,  328 

—  in    pulmonary    tuberculosis, 
314 

—  iu  tubercular  laryngitis,  326 

—  iodized,  288 

—  iron,  288 

—  modifications  of,  273,  278 

—  new,  273 

—  Oberer    273 

—  old,  or  original,  271 
oxy-,  287 

—  Piorkowsky's,  282 
-  Rosenbach's,   282 

—  rtickstand  (T.R.),  273 

—  sanocalcin,  288 

—  therapeutic  use  of,  312 

—  varieties  of,  273 

—  v.  Buck's,  278 
Tuberculocidin,  284 
Tuberculol,  285 
Tuberculomucin,  283 
Tuberculoplasmin,  279 
Tuberculosis,  270 

—  agglutination  test  in,  289 

—  complement-fixation  in,  295 

—  nature  of  immunity  to,  311 

—  pulmonary,  160,  314,  435 

—  serum  diagnosis  of,  289 

—  treatment  of,  337 
surgical,  321 

—  vaccination   against,    329 

—  vaccine  treatment  of,  332 
Tuberculo-toxoidin,  287 
Tulase,  280 

Tumours,   malignant,  422 

—  Coley's  fluid  in,  424 

—  diagnosis  of,  423 

—  serum  treatment  of,  427 

—  vaccine     treatment     of, 
429,  432 

Typhoid  fever  (see  Enteric  fever) 


U 

Ulceration,  gastric,  435 
Ulcerative    endocarditis,    356,    363 
Ulcus  serpens  corneas,  376 

tropicum,  409,  419 

Undulant     fever     (see     Mediter- 
ranean fever) 
Unit,  antitoxic,  100 


456 


INDEX 


Urethritis,  gonococcal,  389 
Urine,  suppression  of,  130 
Urticarial  rash,  130 

V 

Vaccination,  bacterial,  59 
anticholera,   222 

—  antiplague,  207 

—  antirabic,  171 

—  antitubercular,    329 

—  antityphoid,   246 

—  phenomena  of,  69 

—  small-pox,  183 

—  insusceptibility  to,  192 

—  phenomena  of,   187 

—  protection  by,  193,  197 

—  risks  of,  190 

— -  statistics  of,  194 

—  subcutaneous,  186 

—  technique  of,  185,  187 
theory  of,  183 

Vaccine,  anthrax,  203 

—  cholera,  222,  223 
— -  lymph  (see  Lymph) 

—  origin  of  term,  59 

—  treatment  of  coli-infections, 
263 

—  of  diphtheria,  135 

—  of  dysentery,  261 

—  • of  enteric  fever,  252 

— -  of  glanders,  204 

—  of  gonococcic  infections, 
392 

—  of  hay-fever,  402 

—  of  Hodgkin's  disease,  442 

—  of  leprosy,  346 

—  of  Mediterranean  fever, 
397 

— -  of  meningitis,  388 

—  of  nasal  catarrh,  403 

—  of  new  growths,  432 

—  of    pneumococcic    infec- 
tions, 377 

—  of  scarlatina,  372 

—  of   staphylococcic   infec- 
tions, 382 

—  of     streptococcic     infec- 
tions, 362 

—  of  tuberculosis,   332 

—  of  tumours,  432 
theory  of,  59 


Vaccines,  59 

—  administration  of,  72 

as  treatment,  62 

—  autogenous,  64 

autolysed,  394 

—  Haflkine's  plague,  207 

—  Lustig  and  Galeotti's,  211 
preparation  of,  63 

— •  prophylactic,   use   of,    59 
— •  sensitized,  67,  377,  384,  394 
— -  standardization  of,  66 

—  stock,  64,  383,  393 

—  Terni  and  Bandi's,  211 
vaccinial,  184 

—  Wright's  antityphoid,  246 
Vaccinia,  182 

—  gangrenosa    and    haemorrha- 
gica,  191 

generalized,  191 

Variola  (see  Small-pox) 
Venom,  snake-,  action  of,  159 

nature  of,  158 

Vibrio  choleras,  220 
Vulvo-vaginitis,  379 

W 

Wassermann  reaction,  405 

—  in  syphilis,  405,  4U8 

—  quantitative,  407 

—  in     various     conditions, 
409 

modifications  of,  408 

—  significance    and    varia- 
tions of,  409 

Wassermann-Uhlenhuth  test,  90 
Whooping-cough,  266 
Widal's  test,  76,  231 

sources  of  error  in,   231 

value  of,  80,  234 

Wlaefl's  serum,  427 

Wright's  antityphoid  vaccine,  246 


Yaws,  409,  418 
Yellow  fever,  265 
Yersin's    serum,    213 


Zone  of  inhibition,  17 


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Serums,  vaccines  and  toxins 


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